Differences in macrophage expression in induced membranes by fixation method - Masquelet technique using a mouse's femur critical-sized bone defect model

INTRODUCTION

Masquelet's induced membrane technique (MIMT) is an emerging method for reconstructing critical-sized bone defects. However, an incomplete understanding of the underlying biological and physical processes hinders further optimization. This study investigated the effect of different bone-defect fixation methods on macrophage expression in an induced membrane using a novel mouse plate-fixed Masquelet model.

METHODS

Mice were divided into Plate-fixed Masquelet (P-M), Intramedullary-fixed Masquelet (IM-M), Plate-fixed Control (P-C), and Back subfascial (B) groups. In the P-M and IM-M groups, a polymethylmethacrylate (PMMA) spacer was implanted into a 3 mm bone defect, while the defect in the P-C group remained unfilled. In group B, a spacer was inserted under the back fascia to examine membrane formation caused by a simple foreign body reaction. Tissues were collected at 1, 2, and 4 weeks postoperatively. Hematoxylin and eosin (H&E) staining and immunohistochemistry (CD68 and CD163: macrophage markers) were performed to assess macrophage expression within the membrane. qPCR was performed to measure the expression of CD68, CD163, and fibroblast growth factor 2 (FGF2).

RESULTS

Four weeks post-operation, the P-M group presented with minimal callus growth, whereas the IM-M group exhibited vigorous growth. The P-M and IM-M groups displayed a tri-layered membrane structure, which is consistent with the results of previous studies. The IM-M group had significantly thicker membranes, whereas the P-M group exhibited higher expression levels of CD68, CD163, and FGF2. Group P-C showed no osteogenesis, whereas group B maintained a thin, cell-dense membrane structure. The P-M group consistently showed higher gene expression levels than the P-C and P-B groups.

CONCLUSION

This study introduced a mouse plate fixation model for MIMT. The induced membranes could be adequately evaluated in this model. Induced membranes are formed by foreign body reactions to PMMA spacers; however, their properties are clearly different from those of simple foreign body reaction capsules and granulation tissues that infiltrate bone defects, suggesting that they are more complex tissues. The characteristics and expression of macrophages within these induced membranes varied according to the bone defect fixation method.

Impact of low back pain experience on future occurrence of shoulder pain in adolescent baseball players: A 1-year prospective cohort study

BACKGROUND

Low back pain can affect musculoskeletal problems of the upper limb in adolescent overhead athletes. However, few epidemiological studies have examined this causal relationship. This prospective cohort study aimed to investigate the relationship between baseline low back pain experience and the occurrence of future shoulder and elbow pain among high school baseball players.

METHODS

Participants comprised 383 high school baseball players from 43 high school baseball teams who had undergone baseline medical evaluations (a self-completed questionnaire and physical examination). The occurrence of shoulder and elbow pain during a 1-year follow-up and associations with baseline low back pain (positive subjective symptom during the last year at baseline) adjusted for flexibility of the scapulo-thoracic region, shoulder, and lower extremities, such as straight-leg raise angle (hamstring tightness), Thomas test (iliopsoas tightness), heel-buttock-distance (quadriceps tightness) and passive range of motion of the hip were investigated using multivariable analysis.

RESULTS

A total of 307 players (80.2%) participated in the 1-year follow-up survey, with shoulder and elbow pain reported in 75 players (24.4%) and 119 players (38.8%), respectively, during follow-up. After adjusting for factors associated with shoulder pain using logistic regression modeling, significant associations between LBP experienced during the last year at baseline (odds ratio, 2.18; 95% confidence interval, 1.23-3.87; P = 0.0078) and new-onset of shoulder pain were noted.

CONCLUSIONS

Baseline low back pain impacted future shoulder pain in high school baseball players during the 1-year follow-up. Management of shoulder pain warrants careful attention to low back pain.

Clinical characteristics of early-stage lumbar spondylolysis detected by magnetic resonance imaging in male adolescent baseball players

BACKGROUND

Many adolescent athletes experience low back pain; the most common cause is lumbar spondylolysis. Although early identification of lumbar spondylolysis in adolescent athletes is critical, few studies have focused on identifying the early stages of spondylolysis in baseball players. This study aimed to investigate the clinical characteristics of early-stage spondylolysis in male adolescent baseball players.

METHODS

The participants comprised male junior and high school baseball players. Before magnetic resonance imaging, we recorded their demographic data, low back pain characteristics, and physical findings (lumbar flexion, extension, Kemp's test and the provocative tenderness of a spinous process). After the imaging evaluation, the association among low back pain characteristics, physical findings and the final diagnosis (early-stage spondylolysis or not) were investigated using univariate and multivariable analyses.

RESULTS

A total of 171 players were included in this study. Univariate analyses indicated that the characteristics associated with early-stage spondylolysis were longer duration of low back pain (P = 0.0085), low back pain-related interference while running (P = 0.0022), low back pain starting with laterality (P = 0.0001), lumbar extension (P = 0.022), positive Kemp's test (P = 0.020), and the tenderness of a spinous process (P = 0.0003). After adjusting for confounding factors (age and position), we found that early-stage spondylolysis was significantly associated with low back pain duration ≥4 weeks (odds ratio 3.13, 95% confidence interval 1.42-6.92; P = 0.0048), low back pain-related interference while running (odds ratio 2.89, 95% confidence interval 1.30-6.46; P = 0.0094), low back pain starting with laterality (odds ratio 2.78, 95% confidence interval 1.24-6.27; P = 0.0133), and the tenderness of a spinous process (odds ratio 3.00, 95% confidence interval 1.36-6.57; P = 0.0062).

CONCLUSIONS

Male adolescent baseball players with early-stage spondylolysis might have low back pain duration of more than four weeks, low back pain-related interference while running, and a history of low back pain starting with laterality. The tenderness of a spinous process might be helpful in the diagnosis of early-stage spondylolysis in male adolescent baseball players.

Predictors for onset of extended-spectrum beta-lactamase-producing Escherichia coli-induced bacteraemia: a systematic review and meta-analysis

Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli bacteraemia can induce unfavourable clinical outcomes due to delay in appropriate antimicrobial treatment and limited therapeutic options. Therefore, elucidating the predictors of ESBL-producing E. coli-induced bacteraemia is crucial to improve clinical outcomes. However, a literature search did not reveal any studies that incorporate a meta-analysis of the predictors of ESBL-producing E. coli-induced bacteraemia. As such, this review was undertaken to assess current evidence on the predictors of ESBL-producing E. coli-induced bacteraemia. PubMed, Web of Science and Cochrane Library databases were searched for all relevant publications from January 2000 to September 2021. This systematic review evaluated 10 observational studies, comprising a total of 2325 patients with E. coli-induced bacteraemia and 850 (36.6%) ESBL-producing strains. In the meta-analysis, previous antibiotic therapy [pooled risk ratio (RR) 2.72; P<0.001], especially with cephalosporins (pooled RR 4.66; P<0.001) and quinolones (pooled RR 5.47; P<0.001), and urinary catheter use (pooled RR 3.79; P<0.001) were predictive of ESBL-producing E. coli-induced bacteraemia. Antibiotic therapy for patients with the above-mentioned risk factors should be selected considering the possibility of ESBL-producing E. coli-induced bacteraemia compared with non-ESBL-producing E. coli-induced bacteraemia. It is important to elucidate whether appropriate modulation of the identified risk factors can potentially mitigate the risk of ESBL-producing E. coli-induced bacteraemia compared with non-ESBL-producing E. coli-induced bacteraemia.

Computed Tomography and 18F-Fluorodeoxyglucose-Positron Emission Tomography/Computed Tomography Imaging Biomarkers of Lung Invasive Non-mucinous Adenocarcinoma: Prediction of Grade 3 Tumour Based on World Health Organization Grading System

AIMS

To evaluate computed tomography (CT) and 18F-fluorodeoxyglucose-positron emission tomography/computed tomography (18F-FDG-PET/CT) findings of invasive non-mucinous adenocarcinoma (INMA) of the lung as a predictor of histological tumour grade according to 2021 World Health Organization (WHO) classification.

MATERIALS AND METHODS

This retrospective study included consecutive patients with surgically resected INMA who underwent both preoperative CT and 18F-FDG-PET/CT. A three-tiered tumour grade was performed based on the fifth edition of the WHO classification of lung tumours. CT imaging features and the maximum standardised uptake value (SUVmax) were compared among the three tumour grades.

RESULTS

In total, 214 patients with INMA (median age 70 years; interquartile range 65-76 years; 123 men) were histologically categorised: 36 (17%) as grade 1, 102 (48%) as grade 2 and 76 (35%) as grade 3. Pure solid appearance was more frequent in grade 3 (83%) than in grades 1 (0%) and 2 (26%) (P < 0.001). The SUVmax of the entire tumour was higher in grade 3 than in grades 1 and 2 (P < 0.001). Multivariable analysis revealed that pure solid appearance (odds ratio = 94.0; P < 0.001), round/oval shape (odds ratio = 4.01; P = 0.001), spiculation (odds ratio = 2.13; P = 0.04), air bronchogram (odds ratio = 0.40; P = 0.03) and SUVmax (odds ratio = 1.45; P < 0.001) were significant predictors for grade 3 INMAs.

CONCLUSION

Pure solid appearance, round/oval shape, spiculation, absence of air bronchogram and high SUVmax were associated with grade 3 INMAs. CT and 18F-FDG-PET/CT were potentially useful non-invasive imaging methods to predict the histological grade of INMAs.

Age-Related Differences in the Limited Range of Motion of the Lower Extremity and Their Relation to Low Back Pain in Young Baseball Players: A Cross-Sectional Study of 1215 Players

BACKGROUND

Age-related differences in the limited range of motion of the lower extremities and their relationship with low back pain in juvenile athletes have not been well assessed. This study investigated the relationship between low back pain and limited range of motion of the hip and knee in young baseball players during the baseball season.

RESULTS

Participants comprised 1215 baseball players (216 pitchers, 999 fielders) aged 6-16 years who underwent medical checkups (self-completed questionnaire and physical examination). Of the 1215 players, 255 (21.0%) experienced seasonal low back pain requiring rest during the previous year. The prevalence of low back pain and a positive Thomas test, straight-leg-raising test, and heel-to-buttock test increased with age. Univariate analysis revealed that a positive heel-to-buttock test in both the throwing and non-throwing arm sides in the 11-12 age group and a positive Thomas test in the throwing arm side in the 13-14 age group were associated with seasonal low back pain (P = 0.0051, P = 0.021, and P = 0.048, respectively). Multivariate analysis, adjusted for factors associated with low back pain, showed significant associations between the positive heel-to-buttock test (odds ratio 1.75, 95% confidence interval 1.11-2.79; P = 0.016) and low back pain in players aged 11-14 years.

CONCLUSIONS

A positive heel-to-buttock test is potentially associated with low back pain among juvenile baseball players. Particular attention should be paid to the limited range of motion of the knee joint and tightness of the quadriceps femoris muscle among baseball players with low back pain aged 11-14 years.

Predictors of hypervirulent Klebsiella pneumoniae infections: a systematic review and meta-analysis

BACKGROUND

Hypervirulent Klebsiella pneumoniae (hvKp) infections confer notable morbidity and mortality. Differential diagnosis to determine whether the infections are caused by either the hvKp or classical K. pneumoniae (cKp) strain is particularly important for undertaking optimal clinical care and infection control efforts.

AIM

To identify and assess the potential predictors of hvKp infections.

METHODS

PubMed, Web of Science, and Cochrane Library databases were searched for all relevant publications from January 2000 to March 2022. The search terms included a combination of the following terms: (i) Klebsiella pneumoniae or K. pneumoniae and (ii) hypervirulent or hypervirulence. A meta-analysis of factors for which risk ratio was reported in three or more studies was conducted, and at least one statistically significant association was identified.

FINDINGS

In this systematic review of 11 observational studies, a total of 1392 patients with K. pneumoniae infection and 596 (42.8%) with hvKp strains were evaluated. In the meta-analysis, diabetes mellitus and liver abscess (pooled risk ratio: 2.61 (95% confidence interval: 1.79-3.80) and 9.04 (2.58-31.72), respectively; all P < 0.001) were predictors of hvKp infections.

CONCLUSION

For patients with a history of the abovementioned predictors, prudent management, including the search for multiple sites of infection and/or metastatic spread and the enforcement of an early and appropriate source control procedure, should be initiated in consideration of the potential presence of hvKp. We believe that this research highlights the urgent need for increasing clinical awareness of the management of hvKp infections.

Electrophysiological characteristics and catheter ablation of atypical fast-slow atrioventricular nodal reentrant tachycardia using an inferolateral left atrial slow pathway

Background

Understandings of subtypes of atypical atrioventricular nodal reentrant tachycardia (AVNRT) using variants of slow pathway (SP) are still growing. Inferolateral (inf-lat-) left atrial (LA) SP is a rare variant extending into an inf-lat-LA along the mitral annulus (MA).

Purpose

To characterize an unknown subtype of atypical fast-slow (F/S-) AVNRT using an inf-lat-LA-SP as a retrograde limb (inf-lat-LA-F/S-AVNRT).

Methods

This Japanese multicenter retrospective study enrolled 4 patients of inf-lat-LA-F/S-AVNRT that was characterized by the earliest site of atrial activation during tachycardia (EAA) between 3 and 6 o'clock along the MA. The diagnosis was made by an exclusion of AV reentrant tachycardia (AVRT) and atrial tachycardia (AT) according to the standard criteria and was confirmed by successful elimination of tachycardia and the inf-lat-LA-SP.

Results

Surface ECG during tachycardia revealed long RP appearance except one who had short RP due to a short conduction time across the inf-lat-LA-SP. During tachycardia, far-field LA activation preceding near-field activation of coronary sinus (CS) musculature was visible in the CS recording in 2. Retrograde conduction via the inf-lat-LA-SP with a decremental delay was consistently reproducible with ventricular stimulation in 2, 1 of whom had double atrial response, while it was always masked by the presence of a retrograde conduction via the fast pathway in 1 and a retrograde block at the lower common pathway in 1. An injection of a small dose of ATP transiently interrupted a retrograde conduction over the inf-lat-LA-SP, suggesting its ATP-sensitivity. Exclusion of AVRT was made by no resetting of tachycardia with left ventricular extrastimulus in 2 and VA dissociation during overdrive pacing of tachycardia in remaining 2. Exclusion of AT was made by V-A-V response after ventricular entrainment in 1 and termination without atrial capture by ventricular pacing in 2. Ablation of the right-sided SP was unsuccessful to eliminate the tachycardia, but ablation at or near the EAA by transseptal approach was successful to cure the tachycardia, associated with an elimination of a retrograde conduction over the inf-lat-LA-SP following a development of an accelerated junction rhythm in all. Low-frequency potentials preceding local atrial activation, consistent with a retrograde activation via the inf-lat-LA-SP were detected along the MA medial to the EAA in 1.

Conclusions

Differential diagnosis of tachycardia with the EAA in the inf-lat-LA and especially long RP appearance should include inf-lat-LA-F/S-AVNRT. Presumed arrhythmogenic substrate of the inf-lat-LA-SP seemed to be consistent with the remnant of embryogenic AV ring tissue in the electropharmacological and locational characteristics. Successful elimination of this AVNRT can be obtained by ablation of the inf-lat-LA-SP, but not of the right-sided SP.

Funding Acknowledgement

Type of funding sources: None.

POS0734 THE CLINICAL JUDGMENT FOR THE ACCEPTABILITY OF PREGNANCY IN PATIENTS WITH SEROLOGICALLY ACTIVE SLE IN JAPAN: A NATIONWIDE ONLINE SURVEY FROM THE VIGNETTE STUDY

Background

The risk of pregnancy complications, such as gestational hypertension is high in pregnancies with SLE. In addition, the risk of flare is elevated if pregnancy occurs during the high disease activity. The EULAR recommendation provides a checklist for preconception counseling, in which patients with SLE desiring pregnancy were required the condition that the disease activity prior to pregnancy should be stable for 6-12 months in terms of serological activity (1). However, it does not provide specific criteria for serological activity so that physicians should evaluate the risk of pregnancy in each case by their clinical intuitions.

Objectives

In order to uncover the present clinical situation for the acceptability of pregnancy in patients with SLE, we performed questionnaire survey to physicians regarding to the degree of serological activity.

Methods

This cross-sectional study was performed to physicians registered with the Japanese College of Rheumatology from December 2020 to January 2021 using the online survey. The questionnaire asked about the characteristics of physicians, facilities and the permission of pregnancies with SLE using vignette scenarios. In this study, data from vignettes of women visiting a regular outpatient clinic were used. The vignettes varied in age (28 or 35 years), duration of stable disease and serological activity. Analysis methods were descriptive statistics, chi-square test. generalized estimating equations (GEE) was performed to investigate the relationship between the determining permission for pregnancy and the scenario patient’s characteristics (age, period of stable disease, titer of anti ds-DNA antibody)

Results

The questionnaire was distributed to 4946 physicians, and 463 responded. Completion rate (ratio agreed to participate/finished survey) of survey was 91.1%. The median age of physicians was 46 (interquartile range (IQR) 2-10). The specialty was rheumatology (84.9%), other internal medicine (8%), and pediatrics (5.6%). There were no significant differences in patient’s age about the acceptability of pregnancy (coeffficianet -0.02, 95% CI -0.17 -0.01, p=0.42). Case who had been stable for 6 months were more tolerant of pregnancy than case who had been stable for 3 months (coeffficianet 0.12, 95% CI 0.09-0.15, P<0.001) Pregnancy was not allowed in case with mild or high serological activity (mild: coefficient -0.49, 95% CI -0.29- -0.22, p <0.001, high: -0.64, 95% CI -0.65 - -0.61, p <0.001). In contrast, as many as 92 (19.2%) physicians tolerated pregnancy even in the presence of residual high anti ds-DNA antibody titers. Female physicians are significantly more cautious about pregnancy than male when patients have a serologically high activity (12% vs 37.5%, p<0.001). There were no significant differences in specialty status or clinical experience.

Conclusion

We found that even mild serological activity alone had a significant negative effect on the physician’s decision to allow pregnancy. We conclude that current physicians make cautious decisions about pregnancies of patients with SLE following the recommendation. On the other hand, an additional investigation should be performed about the results of pregnancies in patients with serological abnormalities, since there are some physicians who thought that pregnancy may be acceptable for patients with only serological abnormalities if the clinical symptoms are stable.

References

[1]Ann Rheum Dis．2017 Mar;76(3):476-485

Acknowledgements

I would like to express my gratitude to the members of Japan College of Rheumatology who cooperated in filling out the questionnaire.

Disclosure of Interests

Sakiko Isojima: None declared, Nobuyuki Yajima: None declared, Ryo Yanai: None declared, Yoko Miura: None declared, Shingo Fukuma: None declared, Kayoko Kaneko: None declared, Keishi Fujio: None declared, Kenji Oku: None declared, Masakazu Matsushita: None declared, Takako Miyamae: None declared, Takashi Wada: None declared, Yuko Kaneko: None declared, Yoshiya Tanaka Speakers bureau: Y. Tanaka has received speaking fees and/or honoraria from Gilead, Abbvie, Behringer-Ingelheim, Eli Lilly, Mitsubishi-Tanabe, Chugai, Amgen, YL Biologics, Eisai, Astellas, Bristol-Myers, Astra-Zeneca, Grant/research support from: Y. Tanaka has received research grants from Asahi-Kasei, Abbvie, Chugai, Mitsubishi-Tanabe, Eisai, Takeda, Corrona, Daiichi-Sankyo, Kowa, Behringer-Ingelheim, and consultant fee from Eli Lilly, Daiichi-Sankyo, Taisho, Ayumi, Sanofi, GSK, Abbvie., Ayako Nakajima: None declared, ATSUKO MURASHIMA: None declared

POS0760 HIGH LEVELS OF PROTEINS, CELL COUNTS, AND IL-6 IN CEREBROSPINAL FLUID IN PATIENTS WITH NEUROPSYCHIATRIC SYSTEMIC LUPUS ERYTHEMATOSUS ARE ASSOCIATED WITH DAMAGE ACCRUAL OF NON-NEUROPSYCHIATRIC DOMAINS AS WELL AS THAT OF NEUROPSYCHIATRIC DOMAINS

Background

Neuropsychiatric systemic lupus erythematosus (NPSLE) is one of severe organ manifestations and directly associated with neuropsychiatric damages, such as cerebral vascular accident, cognitive impairment, or seizures. However, factors associated with damage accrual of neuropsychiatric and non-neuropsychiatric domains in NPSLE patients remain unknown.

Objectives

The aim of this study was to identify factors associated with damage accrual in patients with NPSLE.

Methods

We reviewed all patients with SLE who had attended our hospital between January 2010 to December 2020 retrospectively and identified those with NPSLE. We analyzed clinical characteristics and laboratory data including cerebrospinal fluid (CSF) in association with the Systemic Lupus International Collaborating Clinics/American College of Rheumatology (SLICC/ACR) damage index (SDI) progression after the onset of NPSLE.

Results

461 patients with SLE were reviewed. Among them, 37 (8.0%) were diagnosed with NPSLE. Thirty-six patients were included in the analysis after excluding one patient with insufficient information. Seventeen (47.2%) patients were diagnosed with NPSLE at the same time with SLE diagnosis and 19 patients were diagnosed at relapse. At NPSLE onset, the mean age was 33.7 years, 35 were female, and the mean SLEDAI-2K was 21.8. Eighteen (50.0%) patients had active lupus nephritis simultaneously at the onset of NPSLE. The most frequent NPSLE types according to the 1999 ACR classification were lupus headache in 10 patients, followed by cerebrovascular disease in 7, seizure disorders in 6, acute confusional state, psychosis and mononeuropathy in 3, and aseptic meningitis in 2. All patients were treated with glucocorticoids, and the mean initial dose of prednisolone was 52.3 mg/day with steroid pulse therapy in 19 patients. Thirty (83.3%) patients were treated with concomitant immunosuppressive treatments. During the observation period with the mean of 10.0 years, 17 (47.2%) patients developed at least one point of SDI. Among them, 9 patients (25.0%) had neuropsychiatric damage progression including cerebrovascular accident in 6, seizures requiring drug treatment for more than 6 months in 2, and cognitive impairment in 1. Non-neuropsychiatric damage was also increased such musculoskeletal in 5, ocular in 3, cardiovascular in 2, renal, gastrointestinal, premature gonadal failure, diabetes, and malignancy in each one case. Neither neuropsychiatric nor overall damage progression were associated with SLEDAI-2K, anti-cardiolipin antibodies positivity, abnormal electroencephalogram, abnormal single photon-emission computed tomography at NPSLE onset or kinds of immunosuppressive treatments. In 21 patients who underwent CSF examination, the high level of CSF IL-6 was associated with neuropsychiatric damage progression (p=0.032). Also, high levels of CSF protein (p=0.030), cell counts (p=0.007), and IL-6 (p=0.032) were associated with overall SDI progression.

Conclusion

CSF IL-6 concentrations are associated with neuropsychiatric damage progression, and high CSF protein, cell counts and IL-6 at onset in patients with NPSLE can predict overall damage accrual.

References

[1]Liang MH, Corzillius M, Bae SC, et al. The American College of Rheumatology nomenclature and case definitions for neuropsychiatric lupus syndromes. Arthritis Rheum 1999; 42: 599–608.

[2]Gladman D, Ginzler E, Goldsmith C, et al. The development and initial validation of the Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index for systemic lupus erythematosus. Arthritis Rheum 1996; 39: 363–369.

Disclosure of Interests

None declared

POS1436 CLINICAL CHARACTERISTICS AND RISK FACTORS OF INVASIVE FUNGAL INFECTION DURING IMMUNOSUPPRESSIVE INDUCTION THERAPY IN PATIENTS WITH CONNECTIVE TISSUE DISEASE

Background

Invasive fungal infection (IFI) is a life-threatening complication among immunosuppressed patients. Whereas intensive immunosuppressive therapy during remission induction phase in patients with connective tissue disease is a major risk of IFI, little is known about the clinical characteristics and risk factors of IFI.

Objectives

This study aims to reveal prevalence, clinical characteristics, and associated risk factors of IFI during immunosuppressive induction therapy in patients with connective tissue disease.

Methods

We reviewed consecutive patients with connective tissue diseases who underwent immunosuppressive remission induction therapy in Keio University Hospital Rheumatology Department from January 2012 to August 2020. Patients with 0.5mg/kg or more equivalent dose of daily prednisone use were included for IFI, diagnosed according to the definition of invasive fungal diseases from EORTC/MSG 2008. Infections caused by Pneumocystis jirovecii were not included.

Results

Among 2701 hospitalized cases, 627 patients had undergone induction or re-induction therapy. Total of 24(3.8%) patients were diagnosed as IFI, of whom there were 8 proven cases and 16 probable cases; 14 aspergillosis, 5 candidiasis, 2 cryptococcosis, 1 phaeohyphomycosis, and 2 cases with unknown pathogen. Median duration from the start of immunosuppressive therapy to the onset of IFI was 95 days (interquartile range, 36,249 days; range, 13-1397 days) and the mean dose of daily prednisolone was 0.53±0.29 mg/kg at the onset of IFI. Total of 11 patients died; 6 patients (25.0%) due to IFI and 5 patients (20.8%) due to the exacerbation of underlying disease. Univariable analysis comparing the IFI and non-IFI groups, age (65.8±3.7 vs. 56.1±0.7; P=0.01), initial prednisolone dose (0.87±0.01 vs 0.95±0.04 mg/kg; P=0.037), the history of methylprednisolone (mPSL) pulse therapy (54.2% vs. 20.0%; P<0.001), tumor necrosis factor (TNF) inhibitor use (8.3% vs. 1.1%; P=0.039), 2 or more immunosuppressant or biologic use (33.3% vs. 12.9%; P=0.010), HbA1c 6.5% or higher (58.3% vs. 28.9%; P=0.003), lowest serum IgG during the clinical course (599.4±62.1 vs 787.7±12.4 mg/dl; P=0.003), and cytomegalovirus reactivation defined by pp65 antigen 6 or higher (33.3% vs. 11.2%; P=0.004) were significantly different, respectively. Sex, body mass index, presence of interstitial lung disease, and the use of cyclophosphamide, rituximab, or interleukin-6 inhibitors were not significantly different. Multivariable analysis revealed older age (for each 10-year increase: OR 1.40, 95% CI 1.03-1.91; P=0.023), the history of methylprednisolone pulse therapy (OR 2.60, 95% CI 1.06-6.77; P=0.049), TNF inhibitor use (OR 11.2, 95% CI 1.70-74.0; P=0.012), and serum IgG less than 550 mg/dl (OR 2.59, 95% CI 1.03-6.55; P=0.041) as the independent risk factors of IFI.

Conclusion

Patients with connective tissue disease with older age, lower serum IgG, mPSL pulse therapy, or TNF inhibitor use are at higher risk of IFI. Further studies are needed to determine the benefit of prophylactic anti-fungal treatment in such patients.

References

[1]De Pauw B, Walsh TJ, Donnelly JP, et al. Revised definitions of invasive fungal disease from the European Organization for Research and Treatment of Cancer/Invasive Fungal Infections Cooperative Group and the National Institute of Allergy and Infectious Diseases Mycoses Study Group (EORTC/MSG) Consensus Group. Clin Infect Dis. 2008;46(12):1813-1821.

Disclosure of Interests:

None declared

POS1424 RISK FACTORS FOR ADVERSE EVENTS OF SULFAMETHOXAZOLE-TRIMETHOPRIM PROPHYLAXIS IN PATIENTS WITH SYSTEMIC RHEUMATIC DISEASES

Background

The prophylactic use of sulfamethoxazole-trimethoprim (SMX/TMP) can reduce the risk for developing pneumocystis pneumonia in immunosuppressed patients with systemic rheumatic diseases, whereas discontinuation of SMX/TMP prophylaxis is frequent due to adverse events (AEs) with this drug.

Objectives

The purpose of this study was to identify risk factors for AEs of SMX/TMP in patients with systemic rheumatic diseases.

Methods

All consecutive patients who were admitted in our hospital for induction treatment between 2012 and 2019 and newly received prophylactic SMX/TMP were included in the study. We divided them into two groups according to the presence or absence of AEs of SMX/TMP leading to discontinuation of the drug and compared clinical characteristics between the AE and non-AE groups. Multivariable analysis was performed to identify risk factors for AEs of SMX/TMP prophylaxis.

Results

A total of 438 patients were included in the study. Rheumatic diseases of the patients were systemic lupus erythematosus (25.3%), anti-neutrophil cytoplasmic antibody associated vasculitis (15.5%), rheumatoid arthritis (11.6%), polymyositis/dermatomyositis (10.7%), IgG4-related disease (8.5%), large vessel vasculitis (7.1%), adult-onset Still’s disease (AOSD; 4.1%), and others (17.2%). Among them, 82 patients (18.7%) stopped SMX/TMP due to AEs. Most frequent AEs were skin rash (36.6%), followed by liver dysfunction (29.3%), thrombocytopenia (19.5%), elevation in serum creatinine levels (15.9%), hyperkalemia (14.6%), hyponatremia (11%), leukopenia (6.1%), and fever (6.1%). Baseline age (61.4±16.4 vs 56.3±16.9 years, p=0.014) and prednisolone dose for remission induction treatment (0.97 vs 0.91 mg/kg/day, p=0.03) were significantly higher in the AE group than in the non-AE group, respectively. In terms of disease type, significantly higher rates of AEs were observed in patients with AOSD than in those with the other diseases (66.7% vs 16.7%, p<0.001; Figure 1). Blood tests at SMX/TMP initiation demonstrated lower lymphocyte counts (10.1 vs 10.8 x102/μl, p=0.049), lower platelet counts (20.9 vs 25.8 x104/μl, p=0.045), lower albumin levels (3.2 vs 3.4 g/dl, p=0.007), higher AST levels (26 vs 23 U/L, p=0.04), higher creatinine levels (0.71 vs 0.67 mg/dl, p=0.047), and higher ferritin levels (167 vs 154 ng/ml, p=0.047) in the AEs group compared with the non-AEs group, respectively. Multivariable analysis identified an older age (OR 1.03, p=0.002) and AOSD (OR 9.72, p<0.001) as independent risk factors for AEs leading to SMX/TMP withdrawal (Table 1).

Conclusion

Old age and AOSD were associated with AEs of SMX/TMP prophylaxis in patients with systemic rheumatic diseases.

Disclosure of Interests

None declared

OP0062 EFFICACY AND SAFETY OF ADALIMUMAB WITH LOW AND HIGH DOSE-METHOTREXATE IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH INADEQUATE RESPONSE TO METHOTREXATE: THE RANDOMISED CONTROLLED MIRACLE STUDY

Background

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that causes not only joint pain but also bone destruction resulting in impairment of quality of life. Tumor necrosis factor inhibitors have improved prognosis of patients with rheumatoid arthritis dramatically, especially in combination with methotrexate, however, the optimal dose of the concomitant methotrexate is unclear.

Objectives

To evaluate the efficacy and safety of adalimumab in combination with reduced dose of methotrexate in patients with early RA with inadequate response to methotrexate.

Methods

The MIRACLE study was a multinational, randomized, open-label study in patients with RA with inadequate response to methotrexate conducted in Asia. It compared low dose and high dose methotrexate upon starting adalimumab. Methotrexate-naive patients with RA with a disease duration of less than two years started methotrexate at 6 to 8 mg/week and increased it to the maximum tolerable dose by week 12. Patients who have not achieved remission according to simplified disease activity index (SDAI) despite methotrexate ≥ 10 mg/week at week 24 were randomised to the maximum tolerable dose of methotrexate group (10 to 25 mg/week) or the reduced dose group (6 to 8 mg/week) and started to receive subcutaneous adalimumab 40 mg every other week. The primary endpoint was non-inferiority in the achievement of SDAI remission at week 48 in the reduced dose group compared with the maximum tolerable dose group with a non-inferiority margin of -15% based on two-sided 90% confidence interval. (NCT03505008)

Results

A total of 300 patients were enrolled in the study. Among them, 291 started methotrexate and were included in the analysis. The mean age was 57.7±15.2 years, female was 74.6%, and the mean disease duration from the diagnosis of RA was 21.1±56.2 days. Anti-CCP antibody was positive in 211 (73.0%) and the mean SDAI at study enrollment was 26.5±12.4. At week 24, with the mean dose of methotrexate of 12.6±2.9 mg/week, 108 patients (37.1%) achieved remission according to SDAI and continued MTX monotherapy. 134 patients (46.0%) were randomised and started adalimumab with 68 patients in the maximum tolerable dose group and 66 patients in the reduced dose group. At week 48, the remission achievement rates were 38.4 % and 44.8 %, respectively, with the adjusted risk difference of the reduced dose group to the maximum tolerable dose group of 6.4% (-7.0% to 19.8%, 90% CI), which met the criterion for noninferiority. No significant difference was found in health assessment questionnaire disability index ≤0.5 (59.1% vs 62.0%, respectively, p=0.72) and in radiological remission rates (Δmodified total Sharp score ≤0.5, 66.3% vs 62.0 %, respectively, p=0.59). Adverse drug reactions tended to be more frequent in the maximum tolerable dose group than in the reduced dose group (22.1% vs 9.1%, respectively, p=0.06).

Conclusion

The MIRACLE randomised study demonstrated that, in patients with inadequate response to methotrexate, the efficacy of adalimumab with reduced dose of concomitant methotrexate was not inferior to that with maximum tolerable dose of methotrexate with better safety profile.

Disclosure of Interests

Hiroya Tamai Speakers bureau: Eisai, Grant/research support from: Eisai, Kei Ikeda Speakers bureau: AbbVie, Eisai, Eli Lilly, Novartis, Gilead, Asahi-Kasei, Grant/research support from: Mitsubishi-Tanabe, Toshiaki Miyamoto: None declared, Hiroaki Taguchi: None declared, Chang-Fu Kuo: None declared, Kichul Shin: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi-Kasei, Astellas, Ayumi, Bristol Myers Squibb, Celgene, Chugai, Eisai, Eli Lilly, Gilead, Glaxo SmithKline, Janssen, Kyorin, Novartis, Pfizer, Sanofi, Tanabe-Mitsubishi, UCB, Paid instructor for: AbbVie, Mitsubishi-Tanabe, Consultant of: AbbVie, Astellas, Bristol Myers Squibb, Eisai, Gilead, Ily Lilly, Grant/research support from: AbbVie, Asahi-Kasei, Eisai, Otsuka, Sanofi, Shionogi, Chugai, Pfizer, Tanabe-Mitsubishi, Eli Lilly, UCB, yutaka okano: None declared, Shinji Sato Speakers bureau: AbbVie, Eisai, Grant/research support from: AbbVie, Eisai, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi-Sankyo, Eisai, Kissei, Takeda, Mitsubishi-Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer-Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, In Ah Choi Speakers bureau: Abbvie, Eisai, Sung-Hwan Park: None declared, Meng-Yu Weng Paid instructor for: Novartis, Eli Lilly, ChuGai, Abbvie, Consultant of: Abbvie, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Boehringer-Ingelheim, Kissei, Mochida, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer-Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yun Jong Lee Grant/research support from: Yuhan, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi-Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Jinhyun Kim: None declared, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Han Joo Baek: None declared, Ping-Ning Hsu: None declared, Chun-Ming Huang Paid instructor for: Abbvie, Pfizer, Tien-Tsai Cheng Paid instructor for: Abbvie, Grant/research support from: Abbvie, Wan-Yu Sung: None declared, Takehiro Taninaga Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Masahiko Mori Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Hideaki Miyagishi Shareholder of: Eisai.co.,Ltd., Employee of: Eisai.co.,Ltd., Yasunori Sato Speakers bureau: Eisai Co., Ltd. Kowa Company, Ltd., Consultant of: MOCHIDA PHARMACEUTICAL CO., LTD, Tsutomu Takeuchi Speakers bureau: Astellas, AbbVie, Ayumi, Bristol Myers Squibb, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Glaxo Smith Kline, Janssen, Mitsubishi-Tanabe, Nippon-kayaku, Novartis, Pfizer, Sanofi, UCB, Grant/research support from: Asahi Kasei, AbbVie, Ayumi, Boehringer-Ingelheim, Chugai, Eisai, Eli Lilly, Mitsubishi-Tanabe, Sanofi, UCB, Yuko Kaneko Speakers bureau: Asahi Kasei, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Elli Lilly, Mitsubishi-Tanabe, Novartis, UCB, Grant/research support from: AbbVie, Chugai, Eisai, Mitsubishi-Tanabe, UCB.

AB0621 Characteristics of Anti-Neutrophil Cytoplasmic Antibody Associated Vasculitis With Severe Peripheral Neuropathy

Background

Peripheral neuropathy is one of major manifestations of anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) and has a significant impingement on patients’ quality of life.1,2

Objectives

The aim of this study was to clarify clinical features of AAV patients with peripheral neuropathy and identify risk factors for severe motor neuropathy.

Methods

All consecutive patients with active, treatment-naïve AAV who were admitted to our hospital between April, 2012 and October, 2021 were reviewed. Patients were divided into two groups according to the presence or absence of peripheral neuropathy, and their baseline clinical characteristics were compared.

Results

A total of 76 patients (microscopic polyangiitis, MPA, n=37, granulomatosis with poly angiitis, GPA, n=24, eosinophilic GPA, EGPA, n=15) were included in the study. Among them, 28 patients (36.8%) had peripheral neuropathy including 12 with MPA, 4 with GPA, and 12 with EGPA. The clinical characteristics of all patients with peripheral neuropathy were younger age (66.0 years versus 74.5 years, p<0.05) and showed higher white blood cell counts (11500/μL versus 8800/μL, p<0.05), higher blood eosinophil counts (788.5/μL versus 139.0/μL, p<0.05), higher creatinine clearance (77.3 mL/min versus 56.3 mL/min, p<0.05), higher levels of serum immunoglobulin (Ig)E (660 IU/mL versus 125 IU/mL, p<0.05), and IgG4 (361.5 mg/dL versus 84.0 mg/dL, p <0.05). In patients with EGPA, the most susceptible type to peripheral neuropathy, 80% of the patients had peripheral neuropathy. Comparison between patients with EGPA with peripheral neuropathy and those without demonstrated significantly younger age (56.0 years versus 80.0 years, p<0.05) and higher blood eosinophil counts (7832/μL versus 2340/μL, p<0.05) were characteristic for the presence of peripheral neuropathy. Patients with EGPA with motor neuropathy (n=8) showed higher white blood cell counts (26850//μL versus 8650//μL, p <0.05) and higher blood eosinophil counts (13134//μL versus 3436//μL, p<0.05) compared with those with only sensory neuropathy (n=4).

Conclusion

Our current study has shown that patients with EGPA are more prone to peripheral neuropathy than patients with MPA or GPA. Severe motor neuropathy was observed only in patients with EGPA and associated with more intense eosinophilic inflammation. Our results suggest that molecular targeted therapy that improves eosinophilic inflammation such as anti-IL-5 therapy is beneficial for peripheral neuropathy.

References

[1]RUTGERS, Abraham; KALLENBERG, Cees GM. Peripheral neuropathy in AAV—when vasculitis hits a nerve. Nature Reviews Rheumatology, 2012, 8.3: 127-128.

[2]NAKAZAWA, Daigo, et al. Pathogenesis and therapeutic interventions for ANCA-associated vasculitis. Nature Reviews Rheumatology, 2019, 15.2: 91-101.

Disclosure of Interests

None declared

POS0530 MOLECULAR SIGNATURE IN SUSTAINED CLINICAL REMISSION INDUCED BY TOCILIZUMAB IN PATIENTS WITH RHEUMATOID ARTHRITIS

Background

Clinical remission is a clinical goal in the treatment of rheumatoid arthritis (RA). Sustained, biologics-free and true remission is an unachieved goal of the “treat-to-target” approach in most patients, and the determinants for achievement are still unclear. In our recent prospective study using multiomics analysis, we proposed that a molecular signature in peripheral whole blood can be a predictor for subsequent disease activity or activities of daily living.1 We also showed that tocilizumab (TCZ) induced deep clinical remission associated with gene expression in peripheral CD4+ T cells.2

Objectives

To consolidate and expand our hypothesis, we investigated the significance of molecular signatures in sustained remission in a larger scale cohort.

Methods

To build and validate the diagnostic model, we collected 73 peripheral blood samples from 30 patients with active RA, 30 patients in clinical remission induced by TCZ and 13 healthy controls. We then collected another 23 samples at a point before TCZ was halted due to sustained clinical remission. In total, 96 samples were analyzed by a multiomics platform, which included RNA sequencing and comprehensive proteomics.

Results

We first developed an optimized partial least-squares regression (PLSR) model using data from 5,436 genes and 255 proteins extracted in our previous model.1 The odds ratio in the model clearly reflected the clinical state with high fidelity (Figure 1). In that study, TCZ induced nearly half of the patients with clinical remission into molecular remission, with an odds ratio of less than zero. To clarify the characteristics of the molecular signature at sustained clinical remission under TCZ continuation, 23 samples were applied to the model. The odds ratio was largely the same as that for clinical remission. Next, we investigated the association with disease flare after cessation of TCZ. At some points before cessation, the median odds ratio in patients who experienced disease flare after stopping TCZ tended to be higher than that in patients with sustained remission after stopping TCZ in the transcriptomics model but not in the proteomics model. Thirty-five differentially expressed genes were identified between the two groups under the conditions of a >1.5-fold change and P-value<0.05.

Figure 1.

Odds ratio in the partial least-squares regression model using transcriptomics (A) and proteomics (B) data from rheumatoid arthritis and healthy control groups

Conclusion

Our larger scale study validated the idea in our previous study that TCZ induces molecular remission. A certain substantial gap associated with prognosis after quitting TCZ may exist as a molecular signature of sustained clinical remission induced by TCZ. These multiomics data sets enable us to understand sustained clinical remission at a molecular level.

References

[1]Nat Commun. 9(1):2775, 2018, 2) Sci Rep.11(1):16691, 2021

Graphs:

Acknowledgements

We acknowledge funding by Chugai Pharmaceutical Co., Ltd.

Disclosure of Interests

Nobuhiko Kajio: None declared, Katsuya Suzuki Speakers bureau: AbbVie, AsahiKasei, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Gilead, Janssen, Mitsubishi Tanabe, Pfizer, Sanofi, Viatris, Consultant of: AbbVie, Asahi Kasei, Janssen, Pfizer, Grant/research support from: Chugai, Daiichi-Sankyo, Eli Lilly, Mitsubishi Tanabe, Ono, Takeda, Kotaro Matsumoto: None declared, Hiroshi Iijima: None declared, Seiji Nakamura: None declared, Yohei Ishizawa: None declared, Jun Inamo: None declared, Masaru Takeshita: None declared, Keiko Yoshimoto: None declared, Yuko Kaneko Speakers bureau: Chugai, Consultant of: Chugai, Grant/research support from: Chugai, Tsutomu Takeuchi Speakers bureau: Chugai, Consultant of: Chugai, Grant/research support from: Chugai.

POS0459 APTAMER-BASED PROTEOMIC SCREENING IN IDENTIFICATION OF PATHOGENIC SIGNAL PATHWAY AND URINARY BIOMARKERS ASSOCIATED WITH HISTOLOGICAL FINDINGS IN LUPUS NEPHRITIS

Background

The current gold standard for the diagnosis and classification, assessment of the severity of lupus nephritis (LN) is a renal biopsy. On the other hand, since the procedure is highly invasive, there is a pressing need to identify biomarkers for predicting the presence and its histological severity of LN. In addition, the background pathogenesis of each histological findings is not clearly understood.

Objectives

The purpose of this study was to elucidate the urine biomarkers for predicting the presence and the severity of histological findings of LN, and to search the pathogenic signal pathway.

Methods

Urine samples from 24 biopsy-proven active LN patients were initially screened for the levels of 1305 distinct human proteins using an aptamer-based-targeted proteomic assay. We developed histological scoring system based on ISN/RPS lesion definitions and classification, NIH activity and chronicity score. Two experienced evaluators assessed the histological scores. Cluster analysis and pathway analysis were performed.

Results

A total of 24 LN patients were included: 20 (83%) had a proliferative histological class (III or IV +/-V), 4 (17%) pure membranous (V). Through cluster analysis, several histological subgroups were extracted according to correlation with each histological finding, and proteins which corelated with each histological scores were analyzed. We focused on two subgroups: one in which including active glomerular histological findings (endocapillary hypercellularity, karyorrhexis, neutrophil infiltration, subendothelial deposits) and the other in which including interstitial histological findings (interstitial inflammation, interstitial fibrosis, tubular atrophy). Histological scores in the former group showed strong positive correlation with protein group which contained 59 proteins (Group A), including CCL21, CXCL10, VCAM1. Histological scores in the latter group corelated with another protein group which contained 85 proteins (Group B), including MCP-1, CCL11. Ingenuity Pathway Analysis showed 16 pathways (PDGF Signaling, Granulocyte Adhesion and Diapedesis, etc) were upregulated in Group A and 11 pathways (IL-17 signaling, Fibrosis signaling pathway, etc) upregulated in Group B. Among group A and group B urine proteins, those showed strong correlation between respective histological findings were validated with ELISA assays.

Conclusion

An aptamer-based-targeted proteomic assay screening by combining with renal histological scoring system suggested several urine proteins can predict the severity and the presence of major renal histological findings, and suggested to be related with the pathogenesis in patients with LN.

Disclosure of Interests

Kazuoto Hiramoto: None declared, Shuntaro Saito: None declared, Hironari Hanaoka: None declared, Katsuya Suzuki: None declared, Jun Kikuchi: None declared, Hiroyuki Fukui: None declared, Ryo Takano Employee of: Mitsubishi Tanabe Pharma Corporation Sohyaku, Fumihiko Miyoshi Employee of: Mitsubishi Tanabe Pharma Corporation Sohyaku, Noriyasu Seki Employee of: Mitsubishi Tanabe Pharma Corporation Sohyaku, Kunio Sugahara Employee of: Mitsubishi Tanabe Pharma Corporation Sohyaku, Yuko Kaneko: None declared, Tsutomu Takeuchi: None declared.

POS1183 RISK FACTORS FOR CYTOMEGALOVIRUS INFECTION IN PATIENTS WITH RHEUMATIC DISEASE; SINGLE-CENTER PROSPECTIVE COHORT STUDY

Background

Cytomegalovirus (CMV) infection is one of serious opportunistic infections for immunosuppressed patients, therefore, identifying patients at risk for CMV infection is of importance. However, no prospective study about CMV infection in systemic rheumatic disease has been reported.

Objectives

To identify risk factors relevant with CMV infection in patients with systemic rheumatic disease during intensive remission induction therapy.

Methods

Consecutive systemic rheumatic disease cases who started intensive immunosuppressive therapy from February 2017 until February 2019 were enrolled. Serum CMV-IgG was measured before the induction therapy, and subsequently, CMV pp65 antigen was monitored weekly. Patients were divided into 2 groups according to the presence or absence of CMV infection, and risk factors for CMV infection were analyzed.

Results

157 patients consisting of 136 CMV-IgG positive and 21 CMV-IgG negative patients were enrolled in the study. Mean age was 60.8 ± 17.4 y/o, and female was 70.7%. The underlying diseases were following; vasculitides 54, systemic lupus erythematosus 27, polymyositis/dermatomyositis 25, rheumatoid arthritis 14, IgG4-related disease 13, mixed connected tissue disease 6, Behçet disease 5, adult-onset Still’s disease 4, and others 9. The initial dose of glucocorticoid (GC) was 48.4 ± 11.5 mg/day (0.91 ± 0.16 mg/kg/day) as prednisolone (PSL) with additional methylprednisolone (mPSL) pulse therapy being conducted in 44 (28.0%). Concomitant immunosuppressive therapies were intravenous cyclophosphamide (IVCY) in 55, calcineurin inhibitor 27, mycophenolate mofetil 16, hydroxychloroquine 5, and methotrexate 4. Concomitant biological agents were rituximab 12, tocilizumab 6, infliximab 2, golimumab 1, and abatacept 1. CMV infection occurred in 52 patients (33.1%), and all of them were CMV-IgG positive before induction therapy (38.2% in the CMV-IgG positive patients). Univariable analysis revealed initial PSL dose >0.91 mg/kg/day (odds ratio [OR] 5.2, p<0.01), IVCY (OR 3.4, p<0.01), diabetes mellitus (OR 5.2, p<0.01), and a history of malignancy (OR 2.9, p=0.02) were independent risk factors for CMV infection. CMV antiviral drugs were administered in 22 patients (42.3%). At the first detection of CMV pp65 antigen, PSL dose ≥37.5 mg/day (OR 5294.8, p<0.01), CMV pp65 antigen-positive cells ≥2 cells/2 slides (OR 16.0, p = 0.04), and serum albumin levels <3.0 g/dL (OR 26.3, p=0.01) were associated with subsequent CMV antiviral drug administration.

Conclusion

CMV infection occurred only in CMV-IgG positive patients with systemic rheumatic diseases who were undergoing intensive remission induction therapy. CMV infection was related with treatment regimen and comorbidities, and the necessity of CMV antiviral treatment was predicted with prednisolone dose, the number of CMV pp65 antigen positive cells, and albumin levels at the first detection of CMV pp65 antigen.

Disclosure of Interests

None declared

POS0257 COMPARISON OF SARS-CoV-2 VACCINE RESPONSE IN PATIENTS WITH INFLAMMATORY RHEUMATIC DISEASE; mRNA-1273 VACCINE INDUCES HIGHER HUMORAL IMMUNOGENICITY THAN BNT162b2

Background

The SARS-CoV-2 messenger RNA (mRNA) vaccines BNT162b2 (Pfizer-BioNTech) and mRNA-1273 (Moderna) have benefitted all countries amid the coronavirus disease 2019 (COVID-19) crisis. Whereas both of them have shown efficacy in preventing COVID-19 illness in healthy participants, there is paucity of data about immunogenicity and safety of mRNA COVID-19 vaccines in patients with autoimmune, inflammatory rheumatic disease. Recent observational studies evaluated mainly BNT162b2, suggesting that glucocorticoids, immunosuppressive agents impair SARS-CoV-2 vaccine responses. However, difference in immune reactions and safety between BNT162b2 and mRNA-1273 have not been clarified in patients with inflammatory rheumatic diseases.

Objectives

To assess humoral and T cell immune responses and safety profiles after two doses of different mRNA vaccine against SARS-CoV-2; BNT162b2 and mRNA-1273.

Methods

We enrolled consecutive, previously uninfected patients with inflammatory rheumatic diseases receiving mRNA vaccine including BNT162b2 and mRNA-1273. Healthy participants receiving BNT162b2 were also recruited as control. Blood samples were obtained 3weeks, 2 months, 3 months, 4 months, and 6 months after second dose of vaccines. We measured titres of neutralizing antibodies against SARS-CoV-2 and calculated seroconversion rates to evaluate humoral responses. We also assessed T-cell immunity responses by using interferon releasing assay against SARS-CoV-2 in a part of the patients. Answers to questionnaires about adverse reactions were obtained from participants.

Results

A total of 974 patients with inflammatory rheumatic diseases and healthy 630 control participants were enrolled. Among them, 796 patients received BNT162b2, 178 patients received mRNA-1273, and all control participants received BNT162b2. Seroconversion rates and neutralizing antibody titres 3 weeks after vaccination were significantly higher in patients with mRNA-1273 and healthy participants with BNT162b2 compared with patients with BNT162b2; seroconversion rates, 97.2% vs 99.5% vs 83.3%, p<0.001; titers of neutralizing antibodies, 29.4±33.9 IU/mL vs 23.9±14.2 IU/mL vs 10.8±16.5 IU/mL, p<0.001, respectively. On another front, T cell reaction against SARS-CoV-2 was similar in both patients with mRNA-1273 and BNT162b2; interferon gamma levels for antigen 1, 1.2±2.1 IU/mL vs 0.8±2.5 IU/mL, p=0.23; and for antigen 2, 1.4±1.9 IU/mL vs 1.0±2.1 IU/mL, p=0.11, respectively. Regarding adverse reaction of each mRNA vaccine, the frequency of systemic adverse reactions including fever and general fatigue are also significantly higher in patients with mRNA-1273 and healthy controls than patients with BNT162b2; fever, 48.0% vs 44.9% vs 10.2%, p<0.001; general fatigue, 70.4% vs 61.8% vs 31.2%, p<0.001, respectively). In longitudinal measurement, neutralizing antibody titres in patients with BNT162b2 were decreased more rapidly than those in healthy controls; 3.3±3.2 IU/mL in patients with BNT162b2 at 4 months and 3.2±4.7 IU/mL in healthy controls with BNT162b2 at 6 months. We identified age, glucocorticoid dose (prednisolone > 7.5mg), use of immunosuppressants including methotrexate, mycophenolate, cyclophosphamide, and tacrolimus are associated with rapid attenuation of humoral responses in patients with BNT162b2.

Conclusion

Our results demonstrated a significant higher humoral immunogenicity and frequency of systemic adverse reaction of the SARS-CoV-2 mRNA-1273 (Moderna) compared with the BNT162b2 (Pfizer-BioNTech) in inflammatory rheumatic disease patients. Glucocorticoid and immunosuppressive agents impaired induction and sustention of neutralizing antibody, and earlier third booster vaccination may be required within 4 months, especially for those receiving BNT162b2.

References

[1]Steensels D, Pierlet N, Penders J et al. JAMA. 2021;326(15):1533–1535.

[2]Friedman MA, Curtis JR and Winthrop KL. Ann Rheum Dis 2021;80:1255–1265.

Disclosure of Interests

None declared

AB0443 LONG-TERM OUTCOMES OF MULTITARGET THERAPY OF MYCOPHENOLATE MOFETIL AND TACROLIMUS IN LUPUS NEPHRITIS: A SINGLE CENTER RETROSPECTIVE ANALYSIS

Background

Recent studies showed the efficacy of multitarget therapy with mycophenolate mofetil (MMF) and calcineurin inhibitor for induction therapy for lupus nephritis (LN)1. However, long-term outcomes have not been well elucidated.

Objectives

We retrospectively analyzed the long-term outcomes of multitarget therapy of MMF and tacrolimus.

Methods

We examined 27 LN patients (4 male, 23 female) treated with multitarget therapy for induction therapy between Oct. 2009 and Nov. 2018 in our department. Complete remission (CR) was defined as 1) UPCR<0.5 g/gCr, and 2) serum creatinine (S-Cr) normal or if abnormal, within 15% of baseline; 1) and 2) were observed in 2 consecutive visits. Relapse was defined as UPCR>1.0 g/gCr or intensification of immunosuppressive treatment after achievement of CR.

Results

The mean age was 38.6±11．6 years old. 17 patients were new-onset LN, and 10 patients were relapse LN. UPCR and eGFR before treatment were 4.42±2.98 g/gCr and 71.5±32.9 mL/min/1.73m2, respectively. Renal histology was Class III in 1, III+V in ４, IV in 12. IV+V in 9 and V in 1 by ISN/RPS 2003 classification. CR at 6 and 12 months were 59% and 74%, respectively. Patients were treated by multitarget therapy for median of 25 months (IQR, 5.5-37). Finally, 26 (96%) patients achieved CR. During multitarget therapy, there were 15 serious adverse events: deep vein thrombosis in 2, myocardial infarctions in 2, cervical intraepithelial neoplasia in 2, heart failure in 1, herpes zoster in 1, viral myocarditis in 1, cytomegalovirus gastroenteritis in 1, cholecystitis in 1, pyelonephritis in 1, bacterial enteritis in 1, sepsis in 1, and breast cancer in 1. During the median observation period of 94 months (IQR, 63-111.5) after the initiation of multitarget therapy, 1 patient died due to sudden death. No patient reached end-stage kidney disease or doubling S-Cr. 16 patients relapsed at median of 32 months (IQR,13.8-64.5) after CR; 8 patients relapsed on multitarget therapy, and 8 patients relapsed after cessation of multitarget therapy. Relapse was associated with chronic lesions in renal biopsy and normal or higher C4 levels at treatment initiation by Kaplan Meier analysis (Log-rank, P=0.006, P<0.001, respectively).

Conclusion

Multitarget therapy effectively induced CR and maintained renal function in long-term period. However, relapse was often observed during or after withdrawal of multitarget therapy.

References

[1]Liu Z, Zhang H, Liu Z, et al. Multitarget therapy for induction treatment of lupus nephritis: a randomized trial. Ann Int Med 2015; 162: 18-26.

Disclosure of Interests

Yoichi Imai: None declared, Hidekazu Ikeuchi: None declared, Junya Suwa: None declared, Yuko Ohishi: None declared, Mitsuharu Watanabe: None declared, Masao Nakasatomi: None declared, Hiroko Hamatani: None declared, Toru Sakairi: None declared, Yoriaki Kaneko: None declared, Keiju Hiromura Speakers bureau: Chugai, Astellas., Grant/research support from: Chugai, Astellas.

The Relationship between Exercise-Induced Low Back Pain, the Fat Infiltration Rate of Paraspinal Muscles, and Lumbar Sagittal Balance

Introduction

Exercise-induced low back pain (EILBP) is induced during anterior trunk tilting when walking or prolonged standing. In some elderly with chronic LBP, the pain is induced by EILBP. The paraspinal muscles play an important role in supporting the spine; therefore, a dysfunction of back muscles and kyphotic alignment are considered to be associated with EILBP. However, few reports are showing the relationship between EILBP and degenerative muscle changes. This study aimed to clarify the relationship between EILBP, degenerative changes of paraspinal muscles, and spinal alignment in an epidemiological study.

Methods

A total of 324 subjects were included in the analysis. The presence of EILBP was determined through a medical interview and physical examination. The subjects underwent lumbar spine magnetic resonance image (MRI) and X-ray. The fat infiltration rate (FIR) of the multifidus, erector spinae, and psoas major were analyzed using MRI. For lumbar sagittal balance, L1 axis S1 distance (LASD) was measured using X-ray images. Multivariate logistic regression analysis was used to analyze the association between the presence of EILBP and FIR or LASD.

Results

The prevalence of EILBP was 21% and it increased with age. The subjects with EILBP had statistically higher FIR of the multifidus, erector spinae, and psoas major than those without EILBP. There was a significant association between the presence of EILBP and higher FIR of the erector spinae at L1-2 and L5-S1 (p<0.05). However, there were no significant associations between EILBP and LASD.

Conclusions

According to the results in this study, EILBP is not rare and the FIR of the erector spinae is associated with the presence of EILBP.

A new method for right ventricular lead implantation into the intraventricular septum

Funding Acknowledgements

Type of funding sources: None.

Background

Right ventricular (RV) lead placement into the interventricular septum is only accurate in 16–48% of cases under conventional fluoroscopic guidance. A previous report showed the importance of individualized left anterior oblique (LAO) projection to improve the success rate of RV lead placement into the interventricular septum. However, this procedure is complicated. We sought to investigate the preprocedural predictors of individualized LAO projection.

Methods

We assessed the relationship between preoperative electrocardiographic parameters and the angle of the interventricular septum obtained using thoracic computed tomography (CT).

Results

In the retrospective derivation cohort group (n=39), the mean angle of individualized LAO assessed by thoracic CT was 53.1±8.9°, and the preoperative electrocardiogram QRS axis was strongly correlated with the interventricular septum axis detected by thoracic CT (R2 = 0.490). In contrast, the preoperative electrocardiographic transitional zone was not associated with the interventricular septum axis (R2 = 0.041, P = 0.78). Using individual LAO projection derived from the preoperative electrocardiogram QRS axis, it was confirmed that the RV lead was placed in the interventricular septum during the pacemaker procedure in the prospective internal validation group (n=30). The success rate for placing the RV lead into the interventricular septum was significantly improved in the internal validation cohort group (93% vs. 64%, P &lt; 0.05). In addition, the N-terminal pro-brain natriuretic peptide level decreased significantly after surgery in the interventricular septal indwelling group.

Conclusions

Individualized LAO angle derived from the preoperative electrocardiogram QRS axis is a new useful and simple method for RV lead implantation into the interventricular septum.

The role of the flexor pronator muscles as dynamic stabilizers against elbow valgus stress in patients with medial ulnar collateral ligament insufficiency

BACKGROUND

The flexor pronator muscles (FPMs) have been reported to act as dynamic stabilizers against valgus forces in overhead-throwing athletes. Several studies have demonstrated the anatomic, biomechanical, and clinical effects of the FPMs. However, no studies have investigated the in vivo kinematics of the FPMs against the valgus forces on the elbow. This study aimed to clarify the clinical contribution of the FPMs as dynamic stabilizers in medial ulnar collateral ligament (MUCL) insufficiency.

METHODS

Eighteen baseball players with MUCL injury participated in this study. The elbow was flexed to 90°, and the forearm was placed in the supinated position. Manual valgus stress was applied to the elbow joint until maximal shoulder external rotation was achieved. The width of the ulnohumeral joint space was measured using ultrasonography, and any changes in medial elbow pain were recorded before and after isometric forearm pronation.

RESULTS

All the subjects had MUCL tenderness and felt medial elbow pain when elbow valgus stress was applied. The width of the medial joint space was significantly larger on the injured side than on the healthy side (5.1 ± 1.0 mm vs. 3.2 ± 1.0 mm) with elbow valgus stress. During isometric forearm pronation, the width of the medial joint space was significantly decreased (3.1 ± 0.9 mm vs. 2.6 ± 1.0 mm) and medial elbow pain had completely diminished.

CONCLUSION

Isometric forearm pronation reduces valgus stress-induced widening of the medial joint space and medial elbow pain in patients with MUCL insufficiency.

The Influence of Chronic Medial Epicondylar Apophysitis on Medial Ulnar Collateral Ligament Insufficiency - Retrospective Cohort Study

Background

This study aimed to investigate the effect of chronic traction apophysitis of the medial epicondyle (MEC) on medial ulnar collateral ligament (MUCL) insufficiency in high school baseball players.

Methods

In this retrospective cohort study, 3034 of 6069 high school baseball players were enrolled. A self-reported questionnaire was distributed to investigate past history of elbow pain and elbow pain during the previous season. Physical examinations to assess tenderness on the MUCL and the elbow valgus stress test (EVST) were performed. Ultrasonography was performed to determine the presence of morphological abnormalities of the anteroinferior aspect of the MEC (MEC lesions).

Results

Participants with MEC lesions had a significantly higher prevalence of past history of elbow pain, elbow pain during the previous season, MUCL tenderness, and positive EVST than those without MEC lesions (P < .05). Multivariate logistic regression analysis revealed that the participants with the fragmented type had the highest risk of past history of elbow pain (odds ratio [OR] = 3.94), elbow pain during the previous season (OR = 2.27), positive EVST (OR = 3.49), and the second highest risk of MUCL tenderness (OR = 2.01) followed by the irregular type (OR = 2.31). Participants with the hypertrophic type had the lowest risk of past history of elbow pain (OR = 2.08), elbow pain during the previous season (OR = 1.42), MUCL tenderness (OR = 1.09), and positive EVST (OR = 1.47).

Conclusion

The presence of chronic non-healed traction apophysitis of the MEC in high school baseball players presented a significantly high risk of elbow pain and MUCL insufficiency.

Fast-slow atrioventricular nodal reentrant tachycardia phenotype mimicking the slow-slow type

Background

Fast-slow (F/S-) atrioventricular (AV) nodal reentrant tachycardia (AVNRT) is characterized by a short atrio-His (AH) interval and the earliest site of atrial activation (EAA) in the proximal coronary sinus (EAA-CS), while slow-slow (S/S-) AVNRT presents a long AH interval and EAA-CS. Those intracardiac appearances are initial indicators for making a diagnosis.

Purpose

To identify an unknown phenotype of F/S-AVNRT.

Methods

Among 46 consecutive patients with F/S-AVNRT, 6 patients (1 man, age 59±9) had an apparent but not typical (pseudo-) S/S-AVNRT during an electrophysiologic study. In 2 patients, pseudo-S/S-AVNRT was clinically documented.

Results

In all 6 patients, the diagnosis of F/S-AVNRT was made by an exclusion of atrial tachycardia with findings of 1) a V-A-V response following ventricular entrainment or 2) termination without atrial capture by ventricular pacing, and an exclusion of AV reentrant tachycardia with a ventriculoatrial dissociation during an initial (so-called QRS transition) zone of ventricular entrainment. An initial A-A-V activation sequence on atrial induction of F/S-AVNRT observed in 1 patient and Wenckebach-type AV block during ongoing F/S-AVNRT developing in 3 patients suggested the presence of the lower common pathway (LCP). Like the typical S/S-AVNRT, pseudo-S/S-AVNRT was induced with atrial stimulation after a jump in the AH interval or double ventricular response. However, in all patients, the pseudo-S/S-AVNRT transited to F/S-AVNRT following AV block in a single cycle and/or pseudo-S/S-AVNRT transited from spontaneously or triggered by atrial contractions. Importantly, on these transitions, the atrial cycle length (CL) and EAA-CS remained unchanged, that is, the atrial CL of S/S-AVNRT was almost identical to that of F/S-AVNRT, suggesting that the essential circuit of both tachycardias was identical. Actually, both tachycardias were cured by ablation at a single site in the traditional slow pathway (SP). Collectively, the pseudo-S/S-AVNRT was diagnosed as another phenotype of F/S-AVNRT accompanied by sustained antegrade conduction via another bystander (likely the left-sided or superior) SP breaking through the His bundle owing to the repetitive antegrade block at the LCP occurring by linking phenomenon, thus representing a long AH interval during the ongoing F/S-AVNRT. When the antegrade conduction is blocked at the bystander SP during the pseudo-S/S-AVNRT, releasing the linking phenomenon, the subsequent antegrade conduction reach the His-bundle via the fast pathway, thus returning to F/S-AVNRT.

Conclusions

An unknown, but not rare F/S-AVNRT phenotype exists that apparently mimics the typical S/S-AVNRT and is also an unknown subtype of apparent S/S-AVNRT. The presence of this pseudo-S/S-AVNRT suggests the limitation of classifying types of AVNRT based on AH and HA intervals during tachycardia. Understandings of this phenotype can advance a diagnosis of atypical AVNRT with multiple phenotypes.

Funding Acknowledgement

Type of funding sources: None.

AB0145 SMARTPHONE- AND SMARTWATCH-ACQUIRED DAILY STEPS, ACTIVITY, AND BAROMETRIC PRESSURES ASSOCIATED WITH SUBJECTIVE MEASURES OF RHEUMATOID ARTHRITIS: A PROSPECTIVE STUDY FOR RA DIGITAL PHENOTYPING

Background:

Symptoms in patients with rheumatoid arthritis (RA) are potentially influenced by exercise load and meteorological change, and often vary from day to day, especially in unstable condition of RA. Patients with RA not infrequently experience worsening of joint symptoms when the load on the joint, such as walking and doing housework, exceeds a moderate range. However, the worsening of joint symptoms is often not observed in the midst of the loading of the joint, but often becomes apparent after a few hours or days.

Objectives:

To elucidate the relationship between smartphone- and smartwatch-acquired daily objective data (barometric pressures, steps, and activity) and daily subjective patient reported outcomes of RA.

Methods:

A smartphone (iPhone 8) and a wristband-type smartwatch (Fitbit Versa 2) were lent to each patient for free. A mobile app was developed and installed into the smartphones to collect patients’ daily subjective RA symptoms including Pt-P-VAS (patient-pain-visual analogue scale), Pt-G-VAS (pt-general-VAS), PtTJCount(68)(patient self-determined tender joint count among 68 joints), PtTJCount(28), PtSJCount(66)(patient self-determined swollen joint count among 66 joints), PtSJCount(28). Also, the smartwatch data and physicians’ assessment were collected from the same subject. Physicians’ and patients’ assessment of TJC, SJC, and G-VAS was independently performed without seeing each other’s assessment.

We conducted a simple linear regression analysis with outcome variables of Pt-P-VAS, Pt-G-VAS, PtTJCount(68), PtTJCount(28), PtSJCount(66), and PtSJCount(28). The independent variables included smartphone-acquired daily steps and barometric pressure of the reported day and the previous day, and smartwatch-acquired minutes of “lightly active (1-3 METs equivalent)”, “fairly active(3-6 METs equivalent)”, and “very active(>6 METs equivalent)” of the reported day and previous day. We defined low barometric pressure as below 1000 hPa. The level of activity was measured by the smartwatch. Patients were blinded to daily barometric pressure data and their daily active time when the patients answered daily symptom questions on the smartphones.

Results:

A total of five patients were enrolled. At baseline, mean (± standard deviation (SD)) age was 50.8±14.8 years; all patients were females; mean disease duration was 6.6±4.9 years; mean SDAI was 18.6±25.5; mean DAS28-CRP was 3.23±1.85; mean morning stiffness was 134±116 min; mean HAQ-DI was 0.7±0.9. Mean observation period was 77.8 days. Because of the missing data, the sample size (N) for the regression analysis varies with the outcomes: Pt-P-VAS and Pt-G-VAS are 250 while PtTJCount and PtSJCount are 260.

The table 1 showed that the patients’ assessment of TJC, SCJ, and G-VAS was correlated well with the physicians’ assessment.

Table 1.Evaluation itemCorrelation between physicians and patients (ρ)Tender Joint Count (68)0.909Tender Joint Count(28)0.913Swollen Joint Count(66)0.896Swollen Joint Count(28)0.890General VAS0.688

The figure 1 showed the change associated with one SD increment in each independent variable with 90% confidence intervals. Low barometric pressure was associated with bad health conditions (high Pt-G-VAS, Pt-P-VAS, and SJCount). Moreover, longer very active time in the previous day (“veryactive_1” in the Figure 1) was associated with bad health condition (high SJCount). Many steps were associated with good health conditions (low Pt-G-VAS, Pt-P-VAS, and SJCount).

Figure 1.

Conclusion:

High barometric pressure was associated with good health conditions, and longer very active time in the previous day was associated with bad health condition. Barometric pressure data and physical activity data acquired by mobile digital devices may predict the change in RA symptoms. Further investigation in larger patient numbers is warranted.

Acknowledgements:

The authors would like to thank Harumi Kondo for her assistance.

Disclosure of Interests:

Keisuke Izumi Speakers bureau: Abbvie, Asahi Kasei Pharma, Bristol Myers Squibb, Chugai Pharmaceutical, Eli-Lily, Mochida Pharmaceutical, Ono Pharmaceutical, Grant/research support from: Abbvie, Asahi Kasei Pharma, Daisuke Moriwaki Employee of: CyberAgent, Inc., Takamichi Toda Employee of: AI Shift, Inc., Misako Higashida-Konishi: None declared, Manami Koyama: None declared, Hisaji Oshima: None declared, yutaka okano Speakers bureau: Asahi Kasei Pharma, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Novartis, Pfizer, Sanofi, Takeda, Taisho, Tanabe-Mitsubishi, and UCB, Shigeru Ko: None declared, Tsutomu Takeuchi Speakers bureau: Abbott Japan Co, Ltd, Bristol–Myers KK, Chugai Pharmaceutical Co, Ltd, Eisai Co, Ltd, Janssen Pharmaceutical KK, Mitsubishi Tanabe Pharma Co, Pfizer Japan Inc, Takeda Pharmaceutical Co, Ltd, Astellas Pharma and Daiichi Sankyo Co, Ltd., Consultant of: Astra Zeneca KK, Eli Lilly Japan KK, Novartis Pharma KK, Mitsubishi Tanabe Pharma Co, Asahi Kasei Medical KK, Abbvie GK and Daiichi Sankyo Co, Ltd., Grant/research support from: Abbott Japan Co, Ltd, Astellas Pharma, Bristol-Myers KK, Chugai Pharmaceutical Co, Ltd, Daiichi Sankyo Co, Ltd, Eisai Co, Ltd, Janssen Pharmaceutical KK, Mitsubishi Tanabe Pharma Co, Pfizer Japan Inc, Sanofi–Aventis KK, Santen Pharmaceutical Co, Ltd, Takeda Pharmaceutical Co, Ltd, Teijin Pharma Ltd, Abbvie GK, Asahikasei Pharma Corp and Taisho Toyama Pharmaceutical Co, Ltd.

AB0253 COMPARISON OF PHARMACODYNAMICS OF METHOTREXATE AS METHOTREXATE-POLYGLUTAMATES CONCENTRATIONS IN RHEUMATOID ARTHRITIS; INTERIM DATA EVALUATION OF MIRACLE STUDY CONDUCTED IN JAPAN, KOREA AND TAIWAN

Background:

Methotrexate (MTX) is the first-line therapy for rheumatoid arthritis (RA). The concentrations of MTX-polyglutamates (PG) in erythrocytes, an active form of MTX, are useful markers for the optimal usage of MTX in patients with RA. The concentrations of MTX-PG have been reported to be different between Japanese and Caucasians. However, the difference among Asian ethnicity remains unclear.

Objectives:

To examine MTX-PG concentrations in association with MTX dose during the first 24 weeks after the initiation of MTX for newly diagnosed RA patients in Japan, Korea and Taiwan.

Methods:

MIRACLE study is a multicenter, open-label, randomized, 48 weeks interventional study conducted in Japan, Korea and Taiwan to evaluate non-inferiority of low dose to high dose of MTX as an add-on therapy to adalimumab in 300 patients with RA who do not achieve remission after 24 weeks MTX monotherapy in stipulated dosage. In the first 24 weeks, MTX was started at 6 to 8 mg/week for newly diagnosed RA patients, and promptly escalated to the maximum tolerable dose in 12 weeks in principle. This interim data evaluation was intended to investigate the differences among countries in the relationship between MTX dose, safety and MTX-PG concentrations in erythrocytes during the first 24 weeks. The efficacy of the treatment is not included at this point.

Results:

A total of 166 patients (106 in Japan, 35 in Korea, 25 in Taiwan) were included in this interim data. The age at treatment initiation was 57.2 years old on average and female was 79.5%. The time course changes in total and individual MTX-PG levels differed in the three countries. At 24 weeks, whereas the mean total MTX-PG concentrations were comparable (112.9 nmol/L in Japan, 104.4 nmol/L in Korea, and 115.7 nmol/L in Taiwan) with a dose of MTX of 12.3 mg/week, 14.1 mg/week, and 12.2 mg/week, respectively, the individual MTX-PG concentrations were different. The MTX-PG1 and MTX-PG2 concentrations were lower in Korea than Japan and Taiwan whereas MTX-PG3, MTX-PG4 and MTX-PG5 concentrations were the highest in Korea.

Conclusion:

The distribution of short-chain and long-chain MTX-PG concentrations were various among Asian countries despite similar dose of MTX administration: NCT03505008.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol–Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Kirin, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB., Grant/research support from: Sanofi, Hideto Kameda Speakers bureau: AbbVie, Pfizer, Consultant of: AbbVie, Grant/research support from: AbbVie, Eisai, Masataka Kuwana Speakers bureau: Astellas, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, Janssen, Mochida, Nippon Shinyaku, Ono Pharmaceuticals, Pfizer, Mitsubishi-Tanabe, Consultant of: Corbus, Grant/research support from: AbbVie, Asahi Kasei Pharma, Boehringer- Ingelheim, Chugai, Eisai, MBL, Nippon Shinyaku, Ono Pharmaceuticals, Mitsubishi-Tanabe, Yutaka Okano: None declared, Tomonori Ishii Speakers bureau: Chugai, Mitsubishi- Tanabe, Glaxo Smith Kline, Pfizer, Eli Lilly, Janssen, AbbVie, Eisai, Astellas, Kei Ikeda Speakers bureau: AbbVie, Eli Lilly, Novartis, Mitsubishi-Tanabe, Eisai, BMS, Grant/research support from: Mitsubishi-Tanabe, Hiroaki Taguchi: None declared, Shinji Sato: None declared, Toshiaki Miyamoto: None declared, Shintaro Hirata Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Ayumi, Bristol Myers Squibb, Chugai, Eisai, Eli Lilly, Janssen, Glaxo Smith Kline, Kissei, Pfizer, Sanofi, Mitsubishi- Tanabe, UCB, Paid instructor for: AbbVie, Mitsubishi- Tanabe, Consultant of: AbbVie, Eisai, Gilead, Grant/research support from: AbbVie, Chugai, Mitsubishi-Tanabe, UCB, Hidekata Yasuoka Speakers bureau: AbbVie, Asahi Kasei Pharma, Astellas, Daiichi- Sankyo, Eisai, Kissei, Takeda, Mitsubishi- Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Janssen, Sanofi, Teijin, Boehringer- Ingelheim, Bayer, Glaxo Smith Kline, Paid instructor for: AbbVie, Consultant of: AbbVie, Asahi Kasei, Grant/research support from: Mitsubishi-Tanabe, Takeda, Daiichi-Sankyo, Chugai, Bristol-Myers, MSD, Astellas, Toshihisa Kojima Speakers bureau: AbbVie, Pfizer, Eisai, Grant/research support from: AbbVie, Sung-Hwan Park: None declared, Kichul Shin: None declared, Han Joo Baek: None declared, Yun Jong Lee Grant/research support from: research fund, In Ah Choi Speakers bureau: Abbvie, Eizai, Grant/research support from: Abbvie, Eizai, Jinhyun Kim: None declared, Ping-Ning Hsu: None declared, Chang-Fu Kuo: None declared, Chun-Ming Huang Paid instructor for: AbbVie, Pfizer, Meng-Yu Weng Consultant of: AbbVie, Wan-Yu Sung: None declared, Wen-Chan Tsai: None declared, Tien-Tsai Cheng Paid instructor for: AbbVie, Grant/research support from: AbbVie, Takehiro Taninaga Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Masahiko Mori Shareholder of: Eisai Co., Ltd., Employee of: Eisai Co., Ltd., Hideaki Miyagishi Employee of: Eisai Co., Ltd., Yasunori Sato: None declared, Tsutomu Takeuchi Speakers bureau: Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, GlaxoSmithKline, Mitsubishi Tanabe, Chugai, Novartis, Eli Lilly, Pfizer, Bristol Myers Squibb, Janssen, UCB, TaishoToyama, Sanofi–Aventis, Nipponkayaku, Taiho, Gilead, Boehringer Ingelheim, Grant/research support from: Asahikasei, Astellas, Abbvie, Daiichi Sankyo, Ayumi, Eisai, Takeda, Mitsubishi Tanabe, Chugai, Eli Lilly, UCB, Sanofi–Aventis, Nipponkayaku, Boehringer Ingelheim

POS0975 CLINICAL CHARACTERISTICS OF NONRADIOGRAPHIC AXIAL SPONDYLOARTHRITIS IN ASIAN COUNTRIES COMPARED TO OTHER REGIONS: RESULTS OF THE INTERNATIONAL CROSS-SECTIONAL ASAS-COMOSPA STUDY

Background:

Clinical characteristics of nonradiographic axial spondyloarthritis (nr-ax-SpA) are highly variable across patients, and may potentially vary across patient populations, particularly due to differing distributions of human leukocyte antigens (HLA) and other genetic factors. The majority of nr-ax-SpA studies have been conducted in Europe, the United States, and small studies are reported from Asia [1].

Objectives:

To delineate clinical characteristics of patients with nr-ax-SpA in Asian countries in comparison to other areas of the world.

Methods:

Utilizing the ASAS-COMOSPA data, an international cross-sectional observational study of SpA patients, we analyzed information on demographics, disease characteristics, comorbidities, and risk factors. Patients were classified by region: Asia (China, Japan, Singapore, South Korea, and Taiwan), and non-Asian countries (Europe, Americas, and Africa); patient characteristics, including diagnosis and treatment, were compared.

Results:

Among 3984 SpA patients included in the study, 1094 were from centers in Asian countries, and 2890 from other regions. 112/780 (14.4%) of axial SpA patients in Asian countries were nr-ax-SpA, substantially less than in other countries (486/1997, 24.3%). Nr-ax-SpA patients in Asian countries compared to nr-ax-SpA in other countries were more likely male (75.9 vs 47.1%), have onset (22.8 vs 27.8 years) and diagnosis (27.2 vs 34.5 years) at younger age, and experience less diagnostic delay (1.88 vs 2.92 years) (Table 1). Nr-ax-SpA patients in Asian countries have higher prevalence of positive HLA-B27 (90.6% vs 61.9%) and fewer peripheral signs such as arthritis, enthesitis, or dactylitis (53.6% vs 66.3%) but have similar rate of extra-articular manifestations (psoriasis, IBD, or uveitis) and co-morbidities. Disease activity, functional impairment, and inflammation on MRI were less in nr-ax-SpA patients in Asian countries. NSAIDs response was higher and use of methotrexate and b-DMARDs were lower among nr-ax-SpA in Asian countries.

Conclusion:

Among axial SpA patients, substantially lower frequency of nr-ax-SpA was observed in Asian countries compared to other regions of the world. Nr-ax-SpA patients in Asian countries were predominantly male, and had younger disease onset with higher HLA-B27 positivity rate and less peripheral signs, and better response to NSAIDs. These results offer an opportunity to improve both early diagnosis and treatment of nr-ax-SpA patients in Asian countries.

Table 1.

Characteristics of nonradiographic axial SpA in Asia versus non-Asian regions

VariablesAsianon-Asian regionsp valueN112486Age at disease diagnosis, yrs27.2 [21.1, 39.6]34.5 [27.7, 41.7]<0.001Diagnostic delay, yrs1.88 [0.27, 5.56]2.92 [0.59, 9.58]0.011Male (%)85 (75.9)229 (47.1)<0.001Sacroiliitis on MRI among tested (%)49 (67.1)341 (82.2)0.005HLA B27 positivity among measured (%)96 (90.6)273 (61.9)<0.001Inflammatory Back Pain (%)107 (95.5)478 (98.4)0.076Arthritis, enthesitis, or dactylitis (%)60 (53.6)322 (66.3)0.016Psoriasis (%)12 (10.7)82 (16.9)0.142Uveitis (%)20 (17.9)81 (16.7)0.870Inflammatory bowel disease (%)5 (4.5)27 (5.6)0.817Elevated CRP (%)37 (33.0)213 (43.8)0.048Physician global assessment (0-10)2.0 [1.0, 5.0]2.0 [1.0, 4.0]0.741Patient global assessment (0-10)3.0 [1.0, 6.0]4.0 [2.0, 6.0]0.012ASDAS-CRP1.40 [0.95, 2.08]1.97 [1.21, 2.78]<0.001BASFI0.8 [0.05, 2.65]2.9 [0.8, 5.6]<0.001Good response to NSAIDs (%)80 (71.4)272 (56.0)0.004Methotrexate use (%)18 (16.1)134 (27.6)0.016Biological DMARDs use (%)27 (24.1)191 (39.3)0.004

References:

[1]López-Medina C, Ramiro S, van der Heijde D, et al. Characteristics and burden of disease in patients with radiographic and non-radiographic axial Spondyloarthritis: a comparison by systematic literature review and meta-analysis. RMD Open. 2019 Nov 21;5(2): e001108.

Acknowledgements:

This study was conducted under the umbrella of the International Society for Spondyloarthritis Assessment (ASAS) and COMOSPA study was supported by unrestricted grants from Pfizer, AbbVie and UCB.

Disclosure of Interests:

Keisuke Ono: None declared, Mitsumasa Kishimoto Speakers bureau: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Consultant of: AbbVie, Amgen-Astellas BioPharma, Asahi-Kasei Pharma, Astellas, Ayumi Pharma, BMS, Chugai, Daiichi-Sankyo, Eisai, Eli Lilly, Gilead, Janssen, Kyowa Kirin, Novartis, Ono Pharma, Pfizer, Tanabe-Mitsubishi, Teijin Pharma, and UCB Pharma, Sho Fukui: None declared, Satoshi Kawaai: None declared, Gautam A. Deshpande: None declared, Kazuki Yoshida Consultant of: OM1, Inc., Grant/research support from: Corrona, LLC, Naomi Ichikawa: None declared, Yuko Kaneko Speakers bureau: AbbVie, Astellas, Ayumi, Bristol-Myers Squibb, Chugai, Eisai, Eli Lilly, Hisamitsu, Jansen, Kissei, Pfizer, Sanofi, Takeda, Tanabe-Mitsubishi, and UCB, Taku Kawasaki: None declared, Kazuo Matsui: None declared, Mitsuhiro Morita: None declared, Kurisu Tada: None declared, Naoho Takizawa: None declared, Naoto Tamura: None declared, Atsuo Taniguchi: None declared, Yoshinori Taniguchi: None declared, Shigeyoshi Tsuji: None declared, Shigeto Kobayashi: None declared, Masato Okada: None declared, Clementina López-Medina: None declared, Anna Moltó Consultant of: AbbVie, Pfizer, MSD, Novartis, Gilead, Lilly and UCB, Grant/research support from: AbbVie, Pfizer, MSD, Novartis, Gilead, Lilly and UCB, Désirée van der Heijde Consultant of: AbbVie, Amgen, Astellas, AstraZeneca, Bayer, BMS, Boehringer Ingelheim, Celgene, Cyxone, Daiichi, Eisai, Eli-Lilly, Galapagos, Gilead, Glaxo-Smith-Kline, Janssen, Merck, Novartis, Pfizer, Regeneron, Roche, Sanofi, Takeda, UCB Pharma, Employee of: Imaging Rheumatology bv. (Director), Maxime Dougados: None declared, Yoshinori Komagata: None declared, Tetsuya Tomita: None declared, Shinya Kaname: None declared.

AB0660 COVID-19 SHARES CLINICAL FEATURES WITH ANTI-MELANOMA DIFFERENTIATION ASSOCIATED PROTEIN 5 POSITIVE DERMATOMYOSITIS AND ADULT STILL’S DISEASE

Background:

The coronavirus disease 2019 (COVID-19), caused by a novel corona virus named SARS-CoV-2, has emerged as a global pandemic. Severe inflammatory process is one of main pathogenesis of COVID-19 and this involves cytokine storm along with overactivation of macrophage. On another front, cytokine storm with macrophage activation is frequently observed in various connective tissue diseases including dermatomyositis with positive antimelanoma differentiation-associated protein 5 (anti-MDA5) autoantibodies and adult Still’s disease. Macrophage activation during inflammatory states is partially characterized by an increased serum ferritin levels and hyperferritinaemia and characteristics shared by the three diseases are a topic of interest to rheumatologists, however, no study has evaluated anti-MDA5-positive dermatomyositis and adult Still’s disease in comparison to COVID-19.

Objectives:

The aim of this study was to highlight the homology and heterogeneity of COVID-19, anti-MDA5 dermatomyositis, and adult Still’s disease by comparing clinical pictures of each disease in order to discuss their respective pathogeneses.

Methods:

We reviewed consecutive, newly diagnosed, untreated patients with COVID-19, anti-MDA5 dermatomyositis, or adult Still’s disease. We compared their clinical, laboratory, and radiological characteristics, including the prevalence of macrophage activation syndrome and lung involvement in each disease.

Results:

The numbers of patients with COVID-19, anti-MDA5 dermatomyositis, and adult-onset Still’s disease with hyperferritinaemia (serum ferritin ≥ 500ng/dL) who were included for main analysis were 22, 14, and 59, respectively. COVID-19 and adult Still’s disease both featured hyperinflammatory status, such as high fever and elevated serum C-reactive protein, whereas COVID-19 and anti-MDA5 dermatomyositis both presented with severe interstitial lung disease and hypoxaemia. While two-thirds of the patients in each group met the criteria for macrophage-activated syndrome that is used in systemic juvenile idiopathic arthritis, the HScore, an indicator of haemophagocytic lymphohistiocytosis, was low in anti-MDA5 dermatomyositis and COVID-19 even in severe or critical cases. The findings of chest computed tomography were similar between COVID-19 and anti-MDA5 dermatomyositis (Figure 1).

Conclusion:

COVID-19 shared clinical features with rheumatic diseases characterised by hyperferritinaemia, including anti-MDA5 dermatomyositis and adult Still’s disease. These findings should be investigated further in order to shed light on the pathogenesis of not only COVID-19 but also the aforementioned rheumatic diseases.

References:

[1]Mehta P, McAuley DF, Brown M, et al. COVID-19: consider cytokine storm syndromes and immunosuppression. Lancet. (2020) 395: 1033-4.

[2]Gono T, Sato S, Kawaguchi Y, et al. Anti-MDA5 antibody, ferritin and IL-18 are useful for the evaluation of response to treatment in interstitial lung disease with anti-MDA5 antibody-positive dermatomyositis. Rheumatology (Oxford). 2012; 51(9):1563-70.

Figure 1.

Imaging characteristics of chest CT scans in patients with COVID-19, anti-MDA5 dermatomyositis, and adult Still’s disease A)Bilateral ground-glass and consolidative opacities with peripheral distribution in COVID-19. B)Bilateral ground-glass opacities with peripheral consolidations in anti-MDA5 dermatomyositis. C)Pleural effusion with pleural thickening on the left side in adult Still’s disease.

Disclosure of Interests:

Yasushi Kondo: None declared., Yuko Kaneko: None declared., Hisoshi Takei: None declared., Hiroya Tamai: None declared., Tsutomu Takeuchi Grant/research support from: received research grants outside the submitted work from Abbvie, Astra Zeneca, Bristol Myers Squibb, Chugai Pharmaceutical, Eisai Pharmaceutical, Janssen Pharmaceutical, Mitsubishi Tanabe Pharma Corporation, Novartis, Takeda Pharmaceutical, Abbott Japan Co., Ltd., Astellas Pharma, Ltd., Daiichi Sankyo, Pfizer, Sanofi–Aventis, Santen Pharmaceutical, Teijin Pharma Ltd., Asahikasei Pharma Corp., SymBio Pharmaceuticals Ltd., Celtrion, Nipponkayaku Co. Ltd., Eli Lilly Japan, and Taisho Toyama Pharmaceutical.

Topological Kagome Magnet Co3Sn2S2 Thin Flakes with High Electron Mobility and Large Anomalous Hall Effect

Magnetic Weyl semimetals attract considerable interest not only for their topological quantum phenomena but also as an emerging materials class for realizing quantum anomalous Hall effect in the two-dimensional limit. A shandite compound Co₃Sn₂S₂ with layered kagome-lattices is one such material, where vigorous efforts have been devoted to synthesize the two-dimensional crystal. Here, we report a synthesis of Co₃Sn₂S₂ thin flakes with a thickness of 250 nm by chemical vapor transport method. We find that this facile bottom-up approach allows the formation of large-sized Co₃Sn₂S₂ thin flakes of high-quality, where we identify the largest electron mobility (∼2600 cm² V^-1 s^-1) among magnetic topological semimetals, as well as the large anomalous Hall conductivity (∼1400 Ω^-1 cm^-1) and anomalous Hall angle (∼32%) arising from the Berry curvature. Our study provides a viable platform for studying high-quality thin flakes of magnetic Weyl semimetal and stimulate further research on unexplored topological phenomena in the two-dimensional limit.

Giant magneto-optical responses in magnetic Weyl semimetal Co3Sn2S2

The Weyl semimetal (WSM), which hosts pairs of Weyl points and accompanying Berry curvature in momentum space near Fermi level, is expected to exhibit novel electromagnetic phenomena. Although the large optical/electronic responses such as nonlinear optical effects and intrinsic anomalous Hall effect (AHE) have recently been demonstrated indeed, the conclusive evidence for their topological origins has remained elusive. Here, we report the gigantic magneto-optical (MO) response arising from the topological electronic structure with intense Berry curvature in magnetic WSM Co₃Sn₂S₂. The low-energy MO spectroscopy and the first-principles calculation reveal that the interband transitions on the nodal rings connected to the Weyl points show the resonance of the optical Hall conductivity and give rise to the giant intrinsic AHE in dc limit. The terahertz Faraday and infrared Kerr rotations are found to be remarkably enhanced by these resonances with topological electronic structures, demonstrating the novel low-energy optical response inherent to the magnetic WSM.

FRI0079 CHARACTERISTICS OF DIFFICULT-TO-TREAT RHEUMATOID ARTHRITIS

Background:

Despite remarkable progress in therapy, not a few patients with rheumatoid arthritis (RA) have not achieved treatment target. Various factors can be ascribed to difficult-to-treat RA, however, little is known about their characteristics.

Objectives:

To clarify characteristics of patients with difficult-to-treat RA in real-world.

Methods:

We reviewed all consecutive RA patients in Keio University Hospital between 2016 and 2017 and collected medical information. We defined patients in moderate disease activity and high disease activity according to disease activity score for 28 joints (DAS28) at the last visit despite more than one year treatment for RA as difficult-to-treat RA and analyzed their clinical characteristics.

Results:

A total of 1693 patients with RA were enrolled in the analysis. The mean age at the last visit was 64 years old, female was 83%, and the mean disease duration was 11.9 years. Rheumatoid factor and anti-cyclic citrullinated peptide were positive for 76% and 75% of the patients, respectively. The current treatment were conventional synthetic disease modifying anti-rheumatic drugs in 73%, biologic agents or janus kinase (JAK) inhibitors in 57%, and glucocorticoids in 13%. Disease activity according to DAS28 was remission in 65%, low disease activity in 21%, and moderate/high disease activity in 14%, which was defined as difficult-to-treat RA. Characteristics of difficult-to-treat RA were the mean age of 70 years old, female of 89%, and the mean disease duration of 14.8 years. The current treatments were conventional synthetic disease modifying anti-rheumatic drugs alone in 40.7%, biologic agents or JAK inhibitors in 55.8%, and glucocorticoids in 29.0%. The causes of difficult-to-treat RA were unresponsiveness to several biologic agents and/or JAK inhibitors in 22.9%, comorbidities in 33.8%, and personal reasons in 39.8% (costs in 35.9%, low adherence in 4.3%, concerns about possible adverse reaction of drugs in 54.3% and high patient global assessment in 5.4%). Patient characteristics were significantly different between the causes; age at RA onset (51 vs 61 vs 51 years, p<0.001), current age (65 vs 77 vs 66 years, p<0.001), estimated glomerular filtration rate (75 vs 61 vs 73 mL/min/1.73m2, p<0.001), tender joint count (3.4 vs 1.6 vs 2.1, p=0.005), swollen joint count (3.1 vs 1.6 vs 2.9, p=0.003), evaluator global assessment (21 vs 14 vs 16 mm, p=0.03), health assessment questionnaire-disability index (1.3 vs 1.3 vs 0.9, p=0.005), a history of serious infection (28 vs 41 vs 13%, p<0.001) and rheumatic disease comorbidity index (1.2 vs 2.2 vs 0.9, p<0.001).

Conclusion:

There are still 14% of patients with RA were difficult-to-treat in real world in spite of intensive treatment. Their characteristics are distinct by the cause of difficulty to treat, suggesting the approach to difficult-to-treat RA should be personalized.

References:

[1]Roodenrijs NMT, de Hair MJH, van der Goes MC et al. Characteristics of difficult-to-treat rheumatoid arthritis: results of an international survey. Ann Rheum Dis. 2018;77(12):1705-1709.

[2]de Hair MJH, Jacobs JWG, Schoneveld JLM, van Laar JM. Difficult-to-treat rheumatoid arthritis: an area of unmet clinical need. Rheumatology (Oxford). 2017 Oct 4. doi: 10.1093/rheumatology/kex349.

[3]England BR, Sayles H, Mikuls TR, Johnson DS, Michaud K. Validation of the rheumatic disease comorbidity index. Arthritis Care Res (Hoboken)2015;67(6):865–72.

Disclosure of Interests:

Satoshi Takanashi: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

OP0306 CD11C-SPECIFIC ABLATION OF SHP1 INDUCES AUTOIMMUNE SIALADENITIS SIMILAR TO SJÖGREN’S SYNDROME

Background:

Dendritic cells (DCs) play important roles in inducing immune response as well as maintaining immune tolerance. Src homology 2 domain-containing protein tyrosine phosphatase-1 (Shp1) is a negative regulator of signaling in hematopoietic cells and is expressed in a variety of immune cells including DCs. Shp1 homozygous mutant mice (motheaten mice) develop multiple immunological abnormalities and they die around four weeks after birth because of severe pneumonitis. Motheaten mice produce large amounts of autoantibodies, and besides, B-1a cells, a distinct B cell subset, which are an important source of autoantibodies increase in these mice. The functional abnormality of DCs in motheaten mice has not been characterized, but DCs and macrophages increase in various organs of motheaten mice.

To analyze the function of Shp1 in DCs, we generated Shp1 conditional knockout mice (Shp1 CKO) in whichShp1gene is specifically depleted in CD11c+cells. We found that aged shp1 CKO developed autoimmune glomerulonephritis. We also found that they developed severe tubulointerstitial nephritis (TIN) at the age of 40 weeks, which is characterized by the infiltration of CD11c+and F4/80+cells. CD4+T cells from Shp1 CKO produce much more amount of IFNγ. Collectively, Shp1 in DCs acts as a key regulatory molecule to protect against autoimmunity.

Objectives:

We analyzed salivary glands of CKO to confirm whether they have autoimmune sialadenitis because TIN is known to be the most common renal manifestations of Sjögren’s syndrome in human.

Methods:

Shp1 CKO are generated by crossing a mouse line carrying floxedShp1allele to mice expressing Cre recombinase under the control of the CD11c promoter. Sex- and age-matchedPtpn6fl/fllittermates withoutCregene were studied as controls. We analyzed secretory function of the salivary glands in response to pilocarpine stimulation in Shp1 CKO at the age of 40 weeks or older. We then performed histological examination of salivary glands (submandibular glands and sublingual glands) with light-microscopy and immunohistochemical staining. The mononuclear cells prepared from the salivary glands were analyzed by flow cytometry (FCM). We also quantified anti-SSA/Ro60 antibodies and anti-SSB/LA antibodies by ELISA.

Results:

Shp1 CKO secreted less saliva flow compared to control mice by pilocarpine stimulation. Histological study showed Shp1 CKO exhibited massive infiltration of inflammatory cells in salivary glands associated with periductal foci and periductal fibrosis. Most of infiltrated cells were stained by anti- CD4 or B220 mAbs. FCM revealed that B cells increased in the salivary glands of Shp1 CKO. In addition, B-1a cells also increased in the salivary glands of the mice. The levels of anti-SSA/Ro60 antibodies and anti-SSB/LA antibodies were increased in Shp1 CKO.

Conclusion:

CD11c-specific ablation of Shp1 induces the ectopic generation of lymphoid structure in salivary glands and impairment of salivary secretion. Autoantibody profile in Shp1 CKO resembled that in human Sjögren’s syndrome. Our findings suggest that aged Shp1 CKO have the potential to become a new mouse model for the analysis of Sjögren’s syndrome.

References:

[1]Green C. M. et al. J Heredity. 1975; 250-258.

[2]Kaneko T. et al. J Immunology. 2012; 5397-540.

[3]Watanabe M. et al. Biochem Biophys Rep. in press.

Disclosure of Interests:

Masato Kinoshita: None declared, Yoriaki Kaneko Grant/research support from: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc.b, Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Mitsuharu Watanabe: None declared, Yoichi Imai: None declared, Shreya Shrestha: None declared, Junya Suwa: None declared, Yuko Ohishi: None declared, Hiroko Hamatani: None declared, Masao Nakasatomi: None declared, Toru Sakairi: None declared, Hidekazu Ikeuchi Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Yoshihisa Nojima: None declared, Keiju Hiromura Grant/research support from: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc.

AB1103 AUTOMATIC FINGER JOINT BONE EROSION SCORE PREDICTION CONSIDERING 2-TIME-POINT X-RAYS OF PATIENTS WITH RHEUMATOID ARTHRITIS BY DEEP LEARNING

Background:

Medical image analysis using deep learning (DL) has been attracting attention. In previous research, we proposed a DL method for detection of joint region and evaluation for bone destruction at a single point in time in hand X-rays of patients with rheumatoid arthritis (RA) [1-2]. However, in the score of van der Heijde-modified total Sharp scores (mTSS) in X-rays, it is difficult to apply the method as it is. In mTSS, score difference between 2-time points is important, and there is a problem that the score at each time varies depending on the doctor who evaluates.

Objectives:

We aimed at developing an mTSS scoring method considering 2-time-point difference with a DL method.

Methods:

A total of 104 X-ray image sets of both hands at two time points with an interval of ≥1 year were randomly obtained from patients with RA who had visited our clinic in 2015. Well-trained doctors determined the erosion scores of MP and PIP/IP joints of each hand in X-rays according to mTSS. These evaluations of hand joints were performed using our developed annotation software tool. In the learning phase, joint images were randomly divided into five sets for 5-fold cross-validation. We utilized a convolutional neural network model, such as SSD [3], for detecting joint regions and classifying the scores (Fig 1).

Figure1.

The models for classification were designed in consideration of the difference in erosion scores of each patient between the 2-time points of X-rays. The loss function of the DL model was defined bellow;

Here, the coefficient γ is designed to reduce the error for another set of scores with equal differences. The first term of the loss function works to optimize the score at each time point, and the second term works to optimize the score difference at both time points. Thus, our method can be trained without being affected by characteristic training data.

Results:

The number of joints with differences in erosion score between the former and latter time points was 1 (-2 points), 9 (-1), 2015 (0), 32 (+1), 17 (+2), and 6 (+3). There were no joints with score changes of -5, -4, -3, +4, and +5 points.

As a performance of predicting the difference in erosion score between the 2-time points of each patient’s X-ray, our models presented a mean error of 0.412 per each joint in one set for 5-cross validation as compared with physicians’ evaluation (Fig 2).

Figure 2.

Conclusion:

Our DL-based models to predict hand joint erosion scores in X-rays were developed with relatively small samples. This suggests that the predictive performance may increase by collecting more training dataset. Next, we will apply our method to the prediction of joint space narrowing score.

References:

[1]Izumi K, Hashimoto M, Suzuki K, et al. Detecting Hand Joint Ankylosis in Radiographic Images Using Deep Learning: A Step in Developing Automatic Radiographic Scoring System for Bone Destruction.Arthritis Rheumatol2018;70 (suppl 10).

[2]Izumi K, Suzuki K, Hashimoto M, et al. SAT0543 AUTOMATIC DETECTION OF HAND JOINT REGION, ANKYLOSIS AND SUBLUXATION IN RADIOGRAPHIC IMAGES USING DEEP LEARNING: DEVELOPMENT OF ARTIFICIAL INTELLIGENCE-BASED RADIOGRAPHIC EVALUATION SYSTEM FOR BONE DESTRUCTION.Annals of the Rheumatic Diseases2019;78 (suppl 2), pp. 1364-1364.

[3]Liu W, Anguelov D, Szgedy C, et al. SSD: single shot multibox detector.European Conference on Computer Vision (ECCV) 2016.

Acknowledgments:

Izumi and Suzuki are contributed equally.

Disclosure of Interests:

Keisuke Izumi Grant/research support from: Asahi Kasei Pharma, Takeda Pharmaceutical Co., Ltd., Speakers bureau: Asahi Kasei Pharma Corp, Astellas Pharma Inc., Bristol Myers Squibb, Chugai Pharmaceutical Co., Ltd., Eli Lilly Japan K.K., Mitsubishi Tanabe Pharma Co., Kanata Suzuki Employee of: Fujitsu Laboratories Ltd., Masahiro Hashimoto: None declared, Toshio Endoh Employee of: Fujitsu Laboratories Ltd., Kentaro Doi Employee of: Fujitsu Ltd., Yuki Iwai Employee of: Fujitsu Ltd., Yuko Kaneko Speakers bureau: AbbVie, Eisai Pharmaceutical, Chugai Pharmaceutical Co., Ltd., Bristol Myers Squibb, Astellas Pharma Inc., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Janssen Pharmaceutical K.K., Eli Lilly Japan K.K., Santen Pharmaceutical Co., Ltd., Kyowa Hakko Kirin Co. Ltd. and UCB Japan Co. Ltd., Masahiro Jinzaki: None declared, Shigeru Ko Grant/research support from: Fujitsu Ltd., Tsutomu Takeuchi Grant/research support from: Astellas Pharma Inc, Chugai Pharmaceutical Co, Ltd., Daiichi Sankyo Co., Ltd., Takeda Pharmaceutical Co., Ltd., AbbVie GK, Asahikasei Pharma Corp., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Eisai Co., Ltd., AYUMI Pharmaceutical Corporation, Nipponkayaku Co. Ltd., Novartis Pharma K.K., Teijin, Consultant of: Astra Zeneca K.K., Eli Lilly Japan K.K., Novartis Pharma K.K., Mitsubishi Tanabe Pharma Co., Abbivie GK, Nipponkayaku Co.Ltd, Janssen Pharmaceutical K.K., Astellas Pharma Inc., Taiho Pharmaceutical Co. Ltd., Chugai Pharmaceutical Co. Ltd., Taisho Toyama Pharmaceutical Co. Ltd., GlaxoSmithKline K.K., UCB Japan Co. Ltd., Speakers bureau: Astellas Pharma Inc., Bristol Myers Squibb, Chugai Pharmaceutical Co., Ltd., Mitsubishi Tanabe Pharma Co., Pfizer Japan Inc., Santen Pharmaceutical Co., Ltd., Takeda Pharmaceutical Co., Ltd., Teijin Pharma Ltd., AbbVie GK, Asahi Kasei Pharma Corp., Taisho Toyama Pharmaceutical Co., Ltd., SymBio Pharmaceuticals Ltd., Janssen Pharmaceutical K.K., Celltrion Inc., Nipponkayaku Co. Ltd., and UCB Japan

SAT0113 DISCORDANCE OF CLINICAL REMISSION AND IMAGING REMISSION BY ULTRASONOGRAPHY IN PATIENTS WITH RHEUMATOID ARTHRITIS WITH BIOLOGIC AGENTS

Background:

Residual synovitis can be detected by sensitive modalities such as ultrasonography in patients with rheumatoid arthritis in clinical remission. On the other hand, a previous study has shown that ultrasound-guided treatment provides modest benefit compared to a conventional strategy aiming clinical remission in early patients. It is still unclear how discordant clinical remission is from imaging remission by ultrasonography in patients treated with biologic agents

Objectives:

To clarify the discordance between clinical remission and imaging remission in patients with rheumatoid arthritis treated with biologic agents.

Methods:

Patients with rheumatoid arthritis who were treated with biologic agents and in clinical remission defined as disease activity score for 28 joints (DAS28)<2.6 were enrolled. All patients were performed comprehensive ultrasound examination of 44 joints as well as physical examinations. Ultrasound images of gray scale (GS) and power doppler (PD) were evaluated with a semi-quantitative score of 0-3. Imaging remission with ultrasound was defined as no PD signal detected in any joints. Clinical information was collected from their medical charts.

Results:

A total of 41 patients were enrolled with 22 patients treated with tumor necrosis factor (TNF)-α inhibitors and 19 with interleukin (IL)-6 inhibitors. The mean age, female ratio, the mean disease duration, and the mean duration of clinical remission were 60 years old, 87%, 5.1 years and 11.5 years. The imaging remission by ultrasonography was observed only in 51.2 %. When patients were divided according to biologic agents, baseline characteristics including median age, disease duration and clinically remission duration were comparable between both groups, while the rates of seropositivity and the stage of radiological progression was higher in IL-6 group (seropositivity, p=0.04; radiological progression, p=0.02). The mean DAS28 was 1.93 in the TNFα group and 1.02 in the IL-6 group. The discordance of clinical remission and imaging remission was observed in 28.6% of the TNFα group and 71.4% of the IL-6 group (p=0.03). The residual synovitis scores of GS and PD in 44 joints were significantly lower in the TNFα than the IL-6 group (GS, 1.1±1.8 vs 4.7 ± 4.6, p<0.01; PD, 0.6 ± 1.3 vs 3.3 ± 3.5, p<0.01, respectively). A receiver operating characteristic curve demonstrated an optimal score of DAS28 that discriminated imaging remission as 1.89 in the TNFα group and 1.25 in the IL-6 group.

Conclusion:

Our results showed that there was substantial discordance between clinical remission and imaging remission, especially in the patients treated with IL-6 inhibitors. In patients treated with biologic agents, clinical remission should be assessed more stringently than the usual 2.6, and ulltrasound-guided management may be useful.

References:

[1]Smolen JS, et al. Ann Rheum Dis 2020;0:1–15.

[2]Iwamoto T, et al. Arthritis Care Res (Hoboken). 2014;66(10):1576-81

[3]Tanaka Y. Ann Rheum Dis 2010;69:1286 –91

[4]Kaneko Y, et al. Ann Rheum Dis 2018;77:1268–1275

[5]Brown AK, et al. Arthritis Rheum 2008;58: 2958 – 67.

Acknowledgments:

We would like to thank Harumi Kondo for their assistance.

Disclosure of Interests:

Yasushi Kondo: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Shuntaro Saito: None declared, Yuichiro Ohta: None declared, Komei Sakata: None declared, Yumiko Inoue: None declared, Chihiro Takahashi: None declared, Kazuoto Hiramoto: None declared, Jun Inamo: None declared, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

FRI0505 TOCILIZUMAB DISCONTINUATION AFTER REMISSION ACHIEVEMENT IN PATIENTS WITH ADULT STILL’S DISEASE

Background:

The efficacy of tocilizumab, an interleukin (IL)-6 receptor inhibitor, has been proved in patients with adult Still’s disease on suppressing systemic inflammation and decreasing glucocorticoid dose. However, whether tocilizumab can be discontinued after remission achievement is unclear.

Objectives:

To clarify the possibility of tocilizumab discontinuation in patients with adult Still’s disease who achieved remission with tocilizumab.

Methods:

Consecutive patients with adult Still’s disease diagnosed according to the Yamaguchi’s criteria in our hospital from April 2012 until September 2019 were retrospectively reviewed. Patients who were in good control with tocilizumab were included in the analysis, and their clinical courses were collected from their medical charts. Patients were divided according to the presence of recurrence after tocilizumab discontinuation and compared.

Results:

Among 42 patients with adult Still’s disease who had a history of intravenous tocilizumab of 8mg/kg use, 13 patients discontinued tocilizumab following a good disease control. During the mean observation period of 26.4 months, six patients (46%) remained in remission while seven patients (54%) developed recurrence after tocilizumab discontinuation. The sex and the mean observation period were not different between the patients with recurrence and those without (71% vs 50%, p=0.43; 27.3 months vs 25.4 months, p=0.93, respectively), but the age at tocilizumab discontinuation tended to be higher in the recurrence group than the non-recurrence group (64.0 years vs 46.5 years, p=0.08). The disease activity including swollen joint counts and laboratory data at tocilizumab discontinuation were comparable between the two groups (serum ferritin levels, 88 ng/mL vs 122 ng/mL, p=0.67). While the duration of tocilizumab use was not different between the two groups (29.4 months vs 39.5 months, p=0.40), the mean interval of tocilizumab infusion at tocilizumab discontinuation in the recurrence group was 3.6 weeks, shorter than the 6.7 weeks in the non-recurrence group (p=0.03). The median dose of prednisolone at tocilizumab discontinuation was 5.0 mg/day in the recurrence group and 0.0 mg/day in the non-recurrence group (p=0.06). In the recurrence group, the duration from the last tocilizumab administration to recurrence was 7.8 months, and the median dose of prednisolone at recurrence was 5.0 mg/day.

Conclusion:

Patients with adult Still’s disease remaining in remission with a longer interval of tocilizumab administration and a lower dose of prednisolone was likely to succeed in withdrawal of tocilizumab.

Disclosure of Interests:

Hiroya Tamai: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

SAT0177 MULTITARGET THERAPY WITH TACROLIMUS AND MYCOPHENOLATE MOFETIL FOR TREATMENT OF LUPUS NEPHRITIS PRESENTED WITH RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS

Background:

Although, most lupus nephritis patients present with chronic glomerulonephritis or nephrotic syndrome, some patients develop rapidly progressive glomerulonephritis (RPGN), which is a clinical syndrome characterized by rapid loss of renal function over a short period of time (days to months). Multitarget therapy using tacrolimus and mycophenolate mofetil (MMF) has been reported to be effective as induction therapy of Class III to Class V lupus nephritis1. However, its efficacy on lupus nephritis presented with RPGN has not been well reported.

Objectives:

We aimed to examine the efficacy of multitarget therapy on lupus nephritis presented with RPGN.

Methods:

We retrospectively analyzed patients with biopsy-proven lupus nephritis, who clinically showed RPGN, and were treated by multitarget therapy with tacrolimus and MMF in our department. Data were expressed as mean±SD.

Results:

Five lupus nephritis patients (3 female) with RPGN were treated by multitarget therapy as induction therapy. Mean age was 36.6±13.5 years old. Renal biopsy at treatment revealed Class IV(A) in 2, Class IV(A+C) in 1 and Class IV(A)+V in 2. The percentage of glomerular crescents was 23.1±25.4%. eGFR and proteinuria at the initiation of treatment were 46.8±11.5 mL/min/1.73m2and 7.7±3.4 g/gCr, respectively. Patients were initially treated with methylprednisolone pulse therapy followed by 0.8-1.0 mg/kg of prednisolone (PSL), 2-3 mg/day of tacrolimus and 1000 mg/day of MMF. At 6 months, eGFR and proteinuria improved to 72.9±11.3 mL/min/1.73m2and 0.19±0.13 g/gCr, respectively. At 12 months, eGFR and proteinuria further improved to 76.8±7.8 mL/min/1.73m2and 0.10±0.07 g/gCr, respectively and the dose of PSL was reduced to 6.6±1.5 mg/day. Three patients became positive for cytomegalovirus antigenemia and were successfully treated with antiviral therapy.

Conclusion:

Multitarget therapy is effective in lupus nephritis even in patients presented with RPGN.

References:

[1]Liu Z, Zhang H, Liu Z,et al. Multitarget therapy for induction treatment of lupus nephritis: a randomized trial.Ann Int Med2015; 162: 18-26.

Disclosure of Interests:

Yoichi Imai: None declared, Hidekazu Ikeuchi Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Junya Suwa: None declared, Yuko Ohishi: None declared, Mitsuharu Watanabe: None declared, Masao Nakasatomi: None declared, Hiroko Hamatani: None declared, Toru Sakairi: None declared, Yoriaki Kaneko Grant/research support from: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc. b, Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Keiju Hiromura Grant/research support from: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc., Speakers bureau: CHUGAI PHARMACEUTICAL CO., LTD.

Astellas Pharma Inc.

SAT0093 CDAI AND DAS28 IN THE MANAGEMENT OF RHEUMATOID ARTHRITIS IN CLINICAL PRACTICE

Background:

The primary therapeutic target for rheumatoid arthritis (RA) is remission, assessed using validated composited measures. Currently, index-based remission frequently used in clinical practice are disease activity (CDAI) and disease activity score for 28 joints (DAS28). Generally, CDAI is believed more stringent than DAS28 in assessing clinical remission, however, this confirmation was mainly derived from trial results.

Objectives:

To investigate the real-world performance of CDAI and DAS28 -erythrocyte sedimentation rate (ESR) in RA.

Methods:

We reviewed consecutive RA patients who are receiving any disease modifying anti-rheumatic drug (DMARDs) in Keio University Hospital between 2016 and 2017 and collected medical information. We focused on the patients in CDAI remission and/or DAS28-ESR remission at the time of last visit, and analyzed their clinical characteristics.

Results:

A total of 1585 patients with RA were reviewed. Their characteristics were mean age of 64 years old, female of 84% and mean disease duration of 12.0 years. Current treatments were conventional synthetic (cs) DMARDs alone, TNF inhibitors (TNFi), IL-6 receptor inhibitors (IL-6i), CTLA-4Ig, and JAK inhibitors (JAKi) in 39.2%, 29.0%, 22.8%, 7.1%, and 1.8% patients, respectively. Of them, 62.7% were in CDAI remission and 64% were in DAS28-ESR remission. Among patients in CDAI remission, the proportion of DAS28-ESR non-remission was 19.4% in those treated with csDMARDs, 18.2% treated with TNFi, 4.2% treated with IL-6i, 27.6% treated with CTLA-4Ig, and 33.3% treated with JAKi (Figure). In contrast, among patients in DAS28 remission, the proportion of CDAI non-remission was 11.7% in those treated with csDMARDs, 15.4% treated with TNFi, 29.5% treated with IL-6i, 16.0% treated with CTLA-4Ig, and 14.3% treated with JAKi. Venn diagrams of CDAI remission and DAS28-ESR remission demonstrated that more patients satisfied the CDAI remission criteria without satisfying the DAS28-ESR remission criteria than vice versa, except for those treated with IL-6i (Figure). Patients in CDAI remission and DAS28-ESR non-remission had higher C-reactive protein, ESR and comorbidity rates (0.37 vs 0.07 mg/dL, p<0.001; 45.7 vs 8.0 mm/h, p<0.001; 26.4 vs 18.0%, p=0.07, respectively), and those in CDAI non-remission and DAS28-ESR remission had worse patient-reported outcomes including patient global assessment and health assessment questionnaire-disability index (31.1 vs 9.5 mm, p<0.001; 0.82 vs 0.41, p<0.001, respectively). Patients in both CDAI and DAS28-ESR remission were apparently in better disease activity than those who met either criteria.

Conclusion:

Assessing patients with two composite measures simultaneously is important to evaluate patients’ condition from view points of RA itself and comorbidities and adjust treatment appropriately.

References:

[1] Smolen JS et al. T2T Expert Committee. Treating rheumatoid arthritis to target: recommendations of an international task force. Ann Rheum Dis. 2010;69(4):631-7.

Disclosure of Interests:

Satoshi Takanashi: None declared, Yuko Kaneko Speakers bureau: Dr. Kaneko reports personal fees from AbbVie, personal fees from Astellas, personal fees from Ayumi, personal fees from Bristol-Myers Squibb, personal fees from Chugai, personal fees from Eisai, personal fees from Eli Lilly, personal fees from Hisamitsu, personal fees from Jansen, personal fees from Kissei, personal fees from Pfizer, personal fees from Sanofi, personal fees from Takeda, personal fees from Tanabe-Mitsubishi, personal fees from UCB, Tsutomu Takeuchi Grant/research support from: Eisai Co., Ltd, Astellas Pharma Inc., AbbVie GK, Asahi Kasei Pharma Corporation, Nippon Kayaku Co., Ltd, Takeda Pharmaceutical Company Ltd, UCB Pharma, Shionogi & Co., Ltd., Mitsubishi-Tanabe Pharma Corp., Daiichi Sankyo Co., Ltd., Chugai Pharmaceutical Co. Ltd., Consultant of: Chugai Pharmaceutical Co Ltd, Astellas Pharma Inc., Eli Lilly Japan KK, Speakers bureau: AbbVie GK, Eisai Co., Ltd, Mitsubishi-Tanabe Pharma Corporation, Chugai Pharmaceutical Co Ltd, Bristol-Myers Squibb Company, AYUMI Pharmaceutical Corp., Eisai Co., Ltd, Daiichi Sankyo Co., Ltd., Gilead Sciences, Inc., Novartis Pharma K.K., Pfizer Japan Inc., Sanofi K.K., Dainippon Sumitomo Co., Ltd.

Disseminated Pneumocystosis in a Toy Poodle

A 1-year and 7-months-old neutered male toy poodle was presented with persistent respiratory distress, gradual weight loss and melaena. Thoracic radiography showed an unstructured interstitial lung pattern. Histopathological examination of tissues collected at necropsy examination revealed disseminated infection by Pneumocystis carinii. The organisms were detected in the lungs, lymph nodes, liver, heart, kidneys, spleen, gastrointestinal tract and pancreas. In the lungs, the organisms were present in the alveolar space and interstitial tissue, and calcified foci containing P. carinii were observed. The presence of the organism in non-thoracic lymph nodes provided evidence of lymphogenous spread. A definitive diagnosis of disseminated pneumocystosis was achieved through the use of Grocott methenamine silver staining, immunohistochemistry (IHC) and polymerase chain reaction for P. carinii. Depletion of cells expressing immunoglobulin (Ig)A and IgG was confirmed by IHC of lymphoid tissue, suggesting possible underlying immunodeficiency.

P585Intra left ventricular hemodynamics assessed using 4D flow MRI in the patient with left ventricular thrombus

Background

Early detection of left ventricular mural thrombus (LVT) in patients with reduced ejection fraction (EF) is crucial in prevention of arterial embolism. 3D-cine phase-contrast magnetic resonance imaging (4D flow MRI) can visualize the intra-LV vortex flow in diastole and quantify the maximum flow velocity (Vmax) at the apex. it remains, however, unknown whether 4D flow MRI is useful for detecting LVT.

Purpose

The purpose of our study is to examine the intra-LV vortex formation and flow velocity in patients with severe LV dysfunction using 4D Flow MRI, and to compare differences in intra-LV flow dynamics between patients with and without LVT. We also examined the diagnostic accuracy to detect LVT by 4D flow MRI.

Methods

Twenty-nine patients with impaired LV function (LVEF 25.8±7.4%, 62.5±12.3 years old, 24 males, 11 with ischemic cardiomyopathy, 9 with LVT) underwent 4D flow MRI from January 2012 to August 2018 in our institution. Intra-LV vortex size was evaluated as vortex/LV area ratio by streamline imaging (Figure 1). The diagnostic accuracy to predict LVT by vortex size and Vmax at the apex was determined by ROC analysis.

Results

The vortex was smaller (vortex/LV area ratio; 30.6±7.0% vs. 45.1±9.0%, p<0.05) and Vmax at the apex was lower (0.20±0.04 m/s vs. 0.28±0.09 m/s, p=0.013) in patients with LVT compared to those without LVT. The AUC was 0.789 for Vmax (cut-off value=0.226 m/s, sensitivity=0.889, specificity=0.650) and was 0.900 for vortex/LV area ratio (cut-off value=34.7%, sensitivity=0.889, specificity=0.850).

Figure 1

Conclusion

The smaller size of intra-LV vortex and the lower flow velocity at the LV apex may have association with LVT formation in patients with reduced EF. 4D flow MRI might be useful to predict LVT formation. Large scale longitudinal study is warranted to evaluate the incidence of LVT in the patients with lower flow velocity.

Acknowledgement/Funding

None

Sufficient duration of off-season decreases elbow disorders in elementary school-aged baseball players

BACKGROUND

Several guidelines for the prevention of throwing injuries recommend a sufficiently long off-season; however, few studies providing scientific evidence to support these recommendations exist. Our study aimed to clarify the association between off-season duration and throwing elbow injuries among elementary school-aged baseball players.

METHODS

This study enrolled 680 elementary school-aged baseball players who underwent medical checkups. The experience with elbow pain and the off-season duration were investigated via the administration of a self-completed questionnaire. Ultrasonographic assessment of the elbow joint was performed on the day of the medical checkup to assess for morphologic abnormalities.

RESULTS

The prevalence of elbow pain and morphologic abnormalities of the medial epicondyle (medial epicondyle lesions) was significantly decreased when the subjects' off-season duration was longer. Multivariate analysis revealed that the risk of elbow pain was significantly lower in the group whose off-season lasted 1 to 2 months (odds ratio [OR], 0.32; 95% confidence interval [CI], 0.15-0.62; P = .0006) and in the group whose off-season lasted longer than 2 months (OR, 0.59; 95% CI, 0.37-0.95; P = .0316). The risk of medial epicondyle lesions was also significantly lower in the group whose off-season lasted 1 to 2 months (OR, 0.39; 95% CI, 0.22-0.67; P = .0005) and in the group whose off-season lasted longer than 2 months (OR, 0.36; 95% CI, 0.23-0.56; P < .0001). On the contrary, no significant correlation was found between capitellar osteochondritis dissecans and off-season duration.

CONCLUSION

Off-season duration has a significant correlation with elbow pain and morphologic abnormalities of the medial elbow joint in elementary school-aged baseball players.

Magnetization-polarization cross-control near room temperature in hexaferrite single crystals

Mutual control of the electricity and magnetism in terms of magnetic (H) and electric (E) fields, the magnetoelectric (ME) effect, offers versatile low power consumption alternatives to current data storage, logic gate, and spintronic devices. Despite its importance, E-field control over magnetization (M) with significant magnitude was observed only at low temperatures. Here we have successfully stabilized a simultaneously ferrimagnetic and ferroelectric phase in a Y-type hexaferrite single crystal up to 450 K, and demonstrated the reversal of large non-volatile M by E field close to room temperature. Manipulation of the magnetic domains by E field is directly visualized at room temperature by using magnetic force microscopy. The present achievement provides an important step towards the application of ME multiferroics.

Mutual control of the electric polarization and magnetization promises for low power consumption spintronic devices but remains challenging. Here the authors show reversal of non-volatile magnetization by electric field as well as the polarization switching by magnetic field in a single-component material, close to room temperature.

Spectral dynamics of shift current in ferroelectric semiconductor SbSI

Photoexcitation in solids brings about transitions of electrons/holes between different electronic bands. If the solid lacks an inversion symmetry, these electronic transitions support spontaneous photocurrent due to the geometric phase of the constituting electronic bands: the Berry connection. This photocurrent, termed shift current, is expected to emerge on the timescale of primary photoexcitation process. We observe ultrafast evolution of the shift current in a prototypical ferroelectric semiconductor antimony sulfur iodide (SbSI) by detecting emitted terahertz electromagnetic waves. By sweeping the excitation photon energy across the bandgap, ultrafast electron dynamics as a source of terahertz emission abruptly changes its nature, reflecting a contribution of Berry connection on interband optical transition. The shift excitation carries a net charge flow and is followed by a swing over of the electron cloud on a subpicosecond timescale. Understanding these substantive characters of the shift current with the help of first-principles calculation will pave the way for its application to ultrafast sensors and solar cells.

Hypertrophic pachymeningitis associated with antineutrophil cytoplasmic antibody-associated vasculitis: a case series of 15 patients

OBJECTIVE

We aimed to describe the clinical characteristics and treatment course of hypertrophic pachymeningitis (HPM) in patients with antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV).

METHODS

We retrospectively analysed 15 patients (11 men and four women). HPM was diagnosed based on thickening and enhancing of the brain and/or spinal dura mater on gadolinium-enhanced magnetic resonance imaging (MRI) T1 sequence.

RESULTS

The median age at HPM onset was 60 years. Headache and cranial nerve impairment were observed in 14 and 10 patients, respectively. Otitis media and/or mastoiditis were found as complications of AAV in 11 patients. Fourteen patients were classified as having granulomatosis with polyangiitis (GPA). Single-positive myeloperoxidase-ANCA, single-positive proteinase 3-ANCA, and double-positive ANCA were identified in seven patients, five patients, and one patient, respectively. With MRI, thickening of the dura mater in the cranial fossa and tentorium cerebelli was found in 10 and eight patients, respectively. For remission induction, all patients were treated with corticosteroids, and immunosuppressants were added in 10 patients. Dura mater thickening partially improved in all patients, and cranial neuropathy completely remitted in eight patients. In a median follow-up of 43 months, four patients had HPM relapse and underwent reinduction therapy. All six patients treated with cyclophosphamide at initial therapy did not relapse.

CONCLUSIONS

HPM was mostly associated with patients with GPA with otitis media and/or mastoiditis having either type of ANCA serology. Treatment with corticosteroids with or without immunosuppressants was effective. However, HPM relapse occasionally occurred, especially when cyclophosphamide was not used in initial treatment.

Effect of genetic polymorphisms of azathioprine-metabolizing enzymes on response to rheumatoid arthritis treatment

Azathioprine (AZA) is increasingly being prescribed to rheumatoid arthritis (RA) patients. Following oral administration, AZA is converted into its active form. Inflammatory bowel disease (IBD) and systemic lupus erythematosus (SLE) patients with low thiopurine (S)-methyltransferase (TPMT) activity tend to respond well to AZA therapy. In a previous study of Japanese SLE patients under low-dose AZA therapy, the group with the 94C>A mutation in inosine triphosphatase (ITPA) showed greater improvement in their disease activity index. However, it is not yet clear how genotypes relate to responsiveness to RA treatment. The genotypes ITPA 94C>A, TPMT*3C, NUDT15 595C>T, GST-M1, GST-T1 and MRP4/ABCC4 2269G>A of Japanese patients with RA were determined. The relationship between these genotypes and response to AZA therapy was evaluated using the Disease Activity Score 28 (DAS28) and various medical data. Of the 22 patients 15 had the ITPA 94C/C genotype, 7 had the ITPA 94C/A genotype, none had the TPMT*3C mutation, 4 had the NUDT15 595C>T mutation, 8 had the GST-M1 and T1 null genotypes and 9 had the MRP4/ABCC4 2269G>A mutation. Changes in DAS28 at 6 months after baseline were similar in both ITPA genotype groups. However, the maintenance dose of AZA was significantly lower in the C/A group than in the C/C group (0.85±0.30 mg/kg/day vs. 1.2±0.46 mg/kg/day, respectively; p = 0.043). The ITPA 94C/A group showed the same response to RA treatment as the C/C group, but at a lower dose. This demonstrates that RA patients with the ITPA 94C>A mutation are more responsive to AZA.

Low-Field Bi-Skyrmion Formation in a Noncentrosymmetric Chimney Ladder Ferromagnet

The real-space spin texture and the relevant magnetic parameters were investigated for an easy-axis noncentrosymmetric ferromagnet Cr_{11}Ge_{19} with Nowotny chimney ladder structure. Using Lorentz transmission electron microscopy, we report the formation of bi-Skyrmions, i.e., pairs of spin vortices with opposite magnetic helicities. The quantitative evaluation of the magnetocrystalline anisotropy and Dzyaloshinskii-Moriya interaction (DMI) proves that the magnetic dipolar interaction plays a more important role than the DMI on the observed bi-Skyrmion formation. Notably, the critical magnetic field value required for the formation of bi-Skyrmions turned out to be extremely small in this system, which is ascribed to strong easy-axis anisotropy associated with the characteristic helix crystal structure. The family of Nowotny chimney ladder compounds may offer a unique material platform where two distinctive Skyrmion formation mechanisms favoring different topological spin textures can become simultaneously active.